Increased Tracer Uptake Left Ischiam Enthesopathy

heel pad (Fig. 12.32A) is difficult if not associated with a bone change, whereas pinhole scin-tigraphy can specifically indicate their diagnosis by showing tracer uptake at the site in question even in the absence of radiographic change (Figs. 12.30B, 12.31B and 12.32B). Established plantar fasciitis always reveals a characteristic calcaneal spur (Fig. 12.33 A). MRI may demonstrate edema in acute tenosynovitis

Fig. 12.30A, B Tenosynovitis of the flexor carpi ulnaris tendon. A Dorsoventral radiograph of a painful left wrist in a 48-year-old woman reveals swelling of the flexor carpi ulnaris tendon (white arrows) (open arrows tendinous insertions in the distal ulna and pisiform, P). B Dorsal pinhole scan shows increased tracer uptake in the ulnar (pair of arrowheads) and pisiform (P single arrowhead) insertions of the flexor carpi ulnaris tendon

(Fig. 12.34A), and contrast arthrography is helpful in the diagnosis of adhesive capsulitis.

99mTc-MDP bone scintigraphy is a valuable imaging modality for the clinical investigation of various nonspecific inflammatory disorders of the periarticular soft-tissue structures, the entheses in particular. Thus, the planar scan shows increased uptake in bursitis, tendonitis, and enthesitis, but, as is well known, the mere tracer uptake is usually inadequate for making a specific diagnosis. Fortunately, pinhole scin-tigraphy provides accurate anatomical information, permitting the diagnosis of, for example, bursitis and tenosynovitis (Figs. 12.25B, 12.28B and 12.30B). In addition, pinhole scanning significantly enhances lesion detectability. As mentioned above, in bursitis and teno-synovitis, bone scanning reveals increased uptake in the erosions, reactive osteitis, or sclerosis in adjacent bone. Such secondary bone changes are typically observed in subdeltoid bursitis (Fig. 12.26), supra-acromial bursitis (Fig. 12.28), subacromial bursitis (Fig. 12.29), trochanteric bursitis, subachilles tenosynovitis (Fig. 12.27), and plantar fasciitis (Fig. 12.32).

12.7.1 Plantar Fasciitis

Plantar fasciitis or calcaneal periostitis, a common cause of painful heel pad, occurs either in isolation or as part of seronegative spondyloarthropathies or Behcet's disease. The usefulness of bone scan for the diagnosis of plantar fasciitis was first described by Sewell et al. (1980), and pinhole scintigraphy is known to indicate the diagnosis even in the absence of radiographic change by showing uptake, which is

Fig. 12.31A-C Adhesive capsulitis of the shoulder. A Anterior planar scan of the left shoulder with pain and limited motion in a 33-year-old man shows no abnormality (?). B Anterior pinhole scan, however, shows the characteristic tracer accumulation in the acromion (a), coracoid (c), subcapsular recess (single arrowhead), and axillary pouch (pair of arrowheads) (bt biceps tendon). C Topography of the left shoulder showing relevant landmarks, including the acromion (a), coracoid (c), and biceps tendon (bt). The subacromial bursa (open arrow), subcapsular recess (single arrowhead), and axillary pouch (pair of arrowheads) are also indicated

Axillary PouchLeft And Right Hindfoot

Fig. 12.32A, B Acute plantar fasciitis without calcaneal spur. A Lateral radiograph of the right hindfoot in a 51-year-old woman with a painful heel pad showing thickening of the plantar soft tissues (arrows) without regional bone abnormality. B Lateral pinhole scan shows subtle tracer uptake in the plantar aspect of the calcaneus at the long plantar tendon insertion (arrows). This uptake could not be appreciated on the plantar scan (not shown)

Fig. 12.32A, B Acute plantar fasciitis without calcaneal spur. A Lateral radiograph of the right hindfoot in a 51-year-old woman with a painful heel pad showing thickening of the plantar soft tissues (arrows) without regional bone abnormality. B Lateral pinhole scan shows subtle tracer uptake in the plantar aspect of the calcaneus at the long plantar tendon insertion (arrows). This uptake could not be appreciated on the plantar scan (not shown)

often extremely subtle, in the calcaneal base and the plantar aponeurosis (Fig. 12.32). An ordinary planar scan is often inefficient for the diagnosis of such lesions. The soft-tissue rheumatism syndromes are local or focal in occurrence, and, hence, it is diagnostically imperative to exclude a possible association with systemic diseases such as rheumatoid arthritis, seronegative spondyloarthropathies, Sjogren's syndrome, Beh├žet's disease, and SLE. In this context, the important roles played by whole-body scanning and pinhole magnification scanning are to be underscored (Kim et al. 1999).

Calcaneal Spur Alponeurosis

Fig. 12.33A, B Chronic plantar fasciitis with calcaneal spur. A Lateral radiograph of the right hindfoot in a 51-year-old woman with a painful heel pad reveals a plantar calcaneal spur (black arrow) with the incidental finding of a small, asymptomatic retrocalcaneal spur (white arrow). B Lateral pinhole scan shows the plantar spur concentrating tracer intensely (arrow), but the retrocalcaneal spur not doing so

Fig. 12.33A, B Chronic plantar fasciitis with calcaneal spur. A Lateral radiograph of the right hindfoot in a 51-year-old woman with a painful heel pad reveals a plantar calcaneal spur (black arrow) with the incidental finding of a small, asymptomatic retrocalcaneal spur (white arrow). B Lateral pinhole scan shows the plantar spur concentrating tracer intensely (arrow), but the retrocalcaneal spur not doing so

12.7.2 Degenerative Rheumatic Enthesopathy

Degenerative rheumatic enthesopathy is a common disorder in the elderly population. It affects any tendinous and ligamentous attachments to bones, causing pain (LaCava 1959; Cooper and Misol 1970). The sites of predilection include the tuberosity of the humerus, ulnar olecranon, patella, ischial tuberosity, tro-

Ishial Enthesopathy

Fig. 12.34A, B Collateral ligament enthesitis. A Anterior pinhole scan of the painful left knee in a 21-year-old man shows intense tracer uptake localized to the lateral femoral epicondyle (arrowhead). B Coronal T2-weighted MRI demonstrates bright signal intensity, denoting edema in the lateral epicondyle where the fibular collateral ligament inserts (arrowhead)

Fig. 12.34A, B Collateral ligament enthesitis. A Anterior pinhole scan of the painful left knee in a 21-year-old man shows intense tracer uptake localized to the lateral femoral epicondyle (arrowhead). B Coronal T2-weighted MRI demonstrates bright signal intensity, denoting edema in the lateral epicondyle where the fibular collateral ligament inserts (arrowhead)

chanters, talus, and calcaneus. Radiography reveals bony erosion in the early stage (Fig. 12.35A) and hyperostosis or bony excrescence in the late stage (Fig. 12.33A). Scintigra-phy is highly sensitive, showing intense uptake

Calcaneus Radiography

Fig. 12.35A, B Early focal rheumatic enthesopathy in the calcaneus. A Lateral pinhole scintigraph of the left ankle in a 57-year-old woman with local pain shows a small "hot" area in the anterior subtalar joint (arrow). B Lateral radiograph reveals a small area of barely recognizable bone resorption at the anterior articular surface of the calcaneal head (open arrow). Clinically, the radiographic change was first overlooked, then found and confirmed retrospectively after pinhole examination

Fig. 12.35A, B Early focal rheumatic enthesopathy in the calcaneus. A Lateral pinhole scintigraph of the left ankle in a 57-year-old woman with local pain shows a small "hot" area in the anterior subtalar joint (arrow). B Lateral radiograph reveals a small area of barely recognizable bone resorption at the anterior articular surface of the calcaneal head (open arrow). Clinically, the radiographic change was first overlooked, then found and confirmed retrospectively after pinhole examination specifically localized to the affected enthesis even in the early phase when radiography is negative or dubious (Fig. 12.35B). As shown in this case, subtle erosions present on a radiograph can frequently be confirmed at a second look after first seeing obvious tracer uptake on scintigraph. Enthesopathic hyperostoses i ntensely accumulate tracer when they are in anactivephase withinflammation(Fig. 12.33B). Another factor for this intense tracer uptake is physical stress to the heel that is hard to avoid. Contusion, strain, and sports injuries may

Pellegrini Stieda Disease

Fig. 12.36 Posttraumatic calcification of the medial collateral ligament of the knee (Pellegrini-Stieda syndrome). Anterior pinhole scintigraphs of both knees (simultaneous acquisition) in a 5-year-old girl shows small, spotty tracer uptake in the medial aspect of the right distal femoral epimetaphysis (open arrow). Radiographically, the uptake was located in the calcified lesion of the collateral ligament (not shown)

Fig. 12.36 Posttraumatic calcification of the medial collateral ligament of the knee (Pellegrini-Stieda syndrome). Anterior pinhole scintigraphs of both knees (simultaneous acquisition) in a 5-year-old girl shows small, spotty tracer uptake in the medial aspect of the right distal femoral epimetaphysis (open arrow). Radiographically, the uptake was located in the calcified lesion of the collateral ligament (not shown)

cause ligamental or tendinous inflammation with ectopic calcification in occasional cases. Such lesions may be visible on soft-tissue radiography if changes are considerable in extent and mineralized. MRI is useful for the demonstration of bone edema that is undetectable ra-diographically (Fig. 12.34A). When mineralization takes place in the medial collateral ligament of the knee, the condition is referred to as Pellegrini-Stieda disease (Fig. 12.36). Pinhole scintigraphy is a highly sensitive imaging method of soft-tissue mineralization, and can simultaneously provide information on the metabolic state of the disease. For example, painful calcified bursitis accumulates tracer avidly, but the quiescent form with calcification does not. Indeed, the calcific bursitis of the great trochanter presented in Fig. 12.25B was painful and did accumulate tracer. However, the calcific bursitis shown in Fig. 12.45 was an incidental finding and did not accumulate tracer; it was an inert and silent lesion.

We had the opportunity to perform pinhole scintigraphy in a patient with chondrocalcino-sis of the knee joint. Interestingly, chondrocal-cinosis in this particular case did not accumulate tracer (Fig. 12.37). This was considered to

Trochanter Calcification

Fig. 12.37A, B Absence of tracer uptake in chondrocal-cinosis. A Anteroposterior radiograph of the right knee in a 52-year-old man with an advanced chondrocalcino-sis shows marked linear calcification in the articular cartilage (arrowheads). B Slightly tilted anterior pinhole scan shows no tracer accumulation in chondrocalcinosis (?) (P patella)

Fig. 12.37A, B Absence of tracer uptake in chondrocal-cinosis. A Anteroposterior radiograph of the right knee in a 52-year-old man with an advanced chondrocalcino-sis shows marked linear calcification in the articular cartilage (arrowheads). B Slightly tilted anterior pinhole scan shows no tracer accumulation in chondrocalcinosis (?) (P patella)

reflect the fact that chondrocalcinosis of this sort has little or no vascular supply, at least during certain stages of its evolution.

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Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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  • nicole
    Can arthritis cause decreased tracer accumulation?
    3 years ago

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