Chapter

Internal Derangements: Menisci

and Cartilage
Kristen E. McClure and William B. Morrison

Meniscus
Anatomy
The medial and lateral menisci of the knee are fibrocartilaginous semicircular structures that act as shock absorbers and
transmit forces between the femur and the tibia. The menisci
are composed of longitudinal collagen bundles, circumferentially oriented in a C-shaped configuration, as well as transversely oriented collagen fibers that radiate from the free edge
of the meniscus to the peripheral margin. Together, these
longitudinal and radial collagen fibers act to provide hoop
tensile strength, resist axial loading extrusive forces, and
prevent separation of the menisci in a radial direction.
Both menisci are thicker in craniocaudad dimension along
the periphery and taper to a thinner margin along the free
edge. Although the medial and lateral menisci serve the same
purpose in the medial and lateral compartments of the knee,
they are not symmetrical in size or shape. The medial meniscus is a larger C-shaped structure, and the lateral meniscus is
a tighter, near complete circle (Fig. 8-1). Because of these
morphologic differences, the medial meniscus covers approximately one half of the tibial plateau contact surface, and the
lateral meniscus covers approximately three quarters of the
tibial plateau contact surface.
The medial meniscus can be differentiated from the lateral
meniscus by position and size, and also by its distinct morphologic characteristics and regional attachments. The
posterior horn of the medial meniscus is wider in an anteroposterior dimension than the anterior horn. This can be
demonstrated on sagittal imaging of the knee when the posterior horn appears two to three times larger than the anterior
horn (Fig. 8-2). The posterior horn of the medial meniscus
attaches to the tibia at the posterior intercondylar fossa, anterior to the posterior cruciate ligament insertion, but behind
the posterior horn of the lateral meniscus. The anterior horn
of the medical meniscus attaches to the tibia at the anterior
intercondylar fossa, in front of both the anterior horn of the
lateral meniscus and the insertion of the anterior cruciate
ligament. The periphery of the medial meniscus is attached
to the joint capsule along its entire length via meniscotibial
and coronary ligaments.12
In comparison, the lateral meniscus is symmetrical from
front to back (Fig. 8-3). Therefore, on sagittal imaging of the
knee, the posterior horn and the anterior horn are similar in
size. The posterior horn of the lateral meniscus attaches to
the tibia behind the intercondylar eminence, anterior to both
the posterior cruciate ligament insertion and the posterior
horn of the medial meniscus. The anterior horn of the lateral
meniscus attaches to the tibia in front of the intercondylar
eminence, behind both the anterior horn of the medial
meniscus and the anterior cruciate ligament insertion. The
fibers of the anterior cruciate ligament partially blend with
106

the lateral meniscus at its tibial attachment. The periphery

of the lateral meniscus cannot attach directly to the joint
capsule because of the intra-articular course of the popliteus
tendon between the lateral meniscus and the joint capsule.
The lateral meniscus actually attaches to the joint capsule
through small fascicles or struts.
Meniscal nutrition is supplied by two routes. The vascular
supply is confined to the outer one third of the meniscus, also
known as the red zone. The vessels arise from the medial and
lateral genicular arteries, forming a perimeniscal synovial
capillary plexus that bathes the periphery of the menisci. The
central portion of the meniscus receives nutrients from
the synovial fluid, which diffuses into or is forced through the
joint with activity. This avascular portion of the meniscus is
known as the white zone. The presence or absence of vascular
supply at the location of a meniscal tear can determine
whether the tear has a possibility of healing without intervention. A peripheral meniscal tear with adequate vascular
supply is capable of healing and may not require surgical
intervention.

Function
The menisci have many biomechanical functions. They act
to increase contact area and joint congruity, transmit load
and absorb shock, prevent radial extrusive forces during axial
loading, and aid in joint lubrication. Because fibrocartilage is
less stiff than hyaline cartilage, the menisci intrinsically have
a higher shock-absorbing capacity. Functional meniscal
studies have found that 50% to 85% of the load placed across
the joint is transmitted by the meniscus. Following total
meniscectomy, the contact area between the femur and the
tibia decreases by approximately 75%; thus contact stresses
between the femur and the tibia increase by more than 200%.
Studies have demonstrated that contact stresses at the knee
joint proportionately increase in relation to the amount of
meniscus removed.12
Discoveries such as these have altered the surgical management of meniscal tears. Preservation and conservation of
meniscal tissue are now the ultimate goals to maximize the
function of the residual meniscus and prevent progression to
osteoarthritis.

Magnetic Resonance Imaging

of the Meniscus
The normal meniscus demonstrates homogeneous low signal
intensity on all imaging sequences because of its short T2
relaxation. Increased signal intensity within the meniscus is
abnormal and represents a meniscal tear or degeneration. A
short time to echo (TE) imaging sequence is necessary to
evaluate the meniscus on magnetic resonance imaging (MRI).

CHAPTER 8 Internal Derangements: Menisci and Cartilage

107

Figure 8-1. A and B, Normal meniscal anatomy. Axial T2-weighted fat-suppressed images at the level of the menisci demonstrate the
larger C-shaped medial meniscus (arrows in A) and the smaller near complete circle lateral meniscus (arrows in B).

Figure 8-2. Normal meniscal anatomy. Sagittal proton density

image through the medial compartment shows that the posterior
horn of the medial meniscus (arrow) typically appears two to
three times larger than the anterior horn (arrowhead).

Figure 8-3. Normal meniscal anatomy. Sagittal proton density

image through the lateral compartment shows that the lateral
meniscus is symmetrical from back (arrow) to front
(arrowhead).

This can be accomplished with proton density, gradient echo,

or traditional spin echo T1-weighted imaging sequences. The
utility of fast spin echo has been debated in the literature,
with some describing blur artifact limitations, and others
reporting similar sensitivities and specificities as conventional spin echo.
T1-weighted images (i.e., low TE images) are the most
sensitive for detecting signal alteration within the meniscus;
however, they are the least specific for meniscal tear. Meniscal vascularity and degeneration, as well as tear, are bright on
low TE images. As TE increases, fluid in true meniscal tears
becomes relatively more prominent. However, not all tears
contain fluid. Therefore, T2-weighted images (i.e., high-TE
images) are specific but not sensitive for tear and are more
useful for confirmation, as fluid signal may be present at the

site of the tear. The best imaging sequence to evaluate for

meniscal tear is a proton densityweighted imaging sequence
that achieves a balance between sensitivity and specificity.
Sagittal proton density images are typically more valuable in
diagnosing a tear of the anterior or posterior horns. However,
meniscal root tears and flipped fragments may be better seen
on coronal imaging, and correlation with two imaging planes
has been encouraged in the interpretation of meniscal pathology.25 Slice thickness can affect sensitivity as well. It has been
recommended that slice thickness be no greater than 4mm,
and that minimal gap exist between each slice.
At our institution, we routinely acquire fast spin echo
sequences, including sagittal proton density images, coronal
T2-weighted images with fat suppression, and sagittal
T2-weighted images with fat suppression. We also acquire

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SECTION 2 Imaging of the Knee

coronal T1-weighted spin echo images, without fat suppression. We use a slice thickness of 3mm with 0.5-mm gaps
between slices. Protocols will vary depending on vendor, field
strength, and user preference.

MRI Criteria for Meniscal Injuries

A meniscal tear can be diagnosed by identifying abnormal
intrameniscal signal, abnormal morphology, or a displaced
meniscal fragment. MRI criteria for diagnosing meniscal tear
were first investigated just over 20 years ago. Abnormal MRI
signal (hyperintensity) within the meniscus in symptomatic
patients was evaluated and subjectively classified prior to
surgery. Intrameniscal signal abnormality was graded according to its confluence and extension to the articular surface on
sagittal imaging. Histologic grading of the same menisci was
performed following surgery, thereby differentiating degeneration from meniscal tear. This histologic grading was correlated with MRI signal grade, as classified below:
Grade 1: punctuate or amorphous signal abnormality
without extension to the articular surface.
Grade 2: linear signal abnormality without extension to
the articular surface.
Grade 3: signal abnormality extending to at least one
articular surface.
In this study, 100% correspondence was noted between
MRI grade signal alteration and histologic grade. MRI grade
1 and 2 signal alterations corresponded with meniscal degeneration. MRI grade 3 signal alteration corresponded with
meniscal tear.20
Later it was described that as the number of sequential
images with abnormal surfacing meniscal signal increased,
the accuracy of diagnosing a meniscal tear also increased. In
two separate studies conducted in 1993 and 2005, the positive
predictive value for diagnosing meniscal tears increased when
two or more images with surfacing signal abnormality were
required compared with only a single abnormal image.8 This
concept was presented as the two-slice-touch rule and is used
by many radiologists today in diagnosing meniscal tear.
These basic MRI criteria were created in the early days
of MRI. Today, with higher-field-strength MRI and
dedicated extremity coils and imaging systems, the original

MRI diagnostic criteria for meniscal tear may not be entirely

applicable. No recent studies have been performed on MRI
at different field strengths to evaluate the difference in diagnostic accuracy between two sequential images with surfacing
signal abnormality and only a single image with surfacing
signal abnormality. With higher signal-to-noise ratio and
improved imaging techniques, the two-slice-touch rule may
not be necessary for accurate diagnosis of meniscal tears.
Although the original MRI criteria are still used as guidelines
at our institution, they are not always strictly adhered to.
Furthermore, secondary signs of meniscal tear have become
more important in our interpretations.
Secondary signs of meniscal tear can enhance confidence
in diagnosis, particularly in cases where the signal abnormality within the meniscus is equivocal, or when the study is
degraded by artifact. Indirect evidence of meniscal pathology
includes adjacent cartilage loss, parameniscal cyst (also
referred to as meniscal cyst), meniscal extrusion, parameniscal soft tissue edema, bowing of the ipsilateral collateral ligament, joint effusion, perivascular bone marrow edema, and
subchondral bone marrow edema (Table 8-1).1
The presence of a parameniscal cyst has a 100% positive
predictive value for an associated meniscal tear in some
studies. Parameniscal cysts are believed to result from extruded
joint fluid through an adjacent meniscal tear.2 Parameniscal
cysts are seen in 7% of meniscal tears (Fig. 8-4). They have
the same incidence for medial and lateral meniscal tears but
are seen more commonly medially owing to higher prevalence of medial tears. Medial meniscal cysts are most frequently located posteriorly, and lateral meniscal cysts are
most frequently located anteriorly.2
Adjacent collateral ligament edema and linear subchondral bone marrow edema have been shown to have high
specificity and positive predictive values in the diagnosis of
meniscal tear.1 Collateral ligament edema can be seen in the
setting of primary ligamentous injury and osteoarthritis.
However in the setting of meniscal tear, collateral ligament
edema likely reflects inflammatory hyperemia, reactive synovitis, and increased fluid formation related to the tear (Fig.
8-5). The sensitivity of this sign is greater for medial meniscal
tears, indicating the closer apposition of the medial collateral
ligament to the periphery of the medial meniscus as compared

Table 8-1 Positive Predictive Value (PPV), Sensitivity, and Specificity of Indirect Signs for Meniscal
Tears at Arthroscopy
MEDIAL

MENISCUS

LATERAL

MENISCUS

Indirect Signs

PPV

Sensitivity

Specificity

PPV

Sensitivity

Specificity

Cartilage loss near tear

0.94

0.54

0.88

0.68

0.23

0.91

Meniscal extrusion

0.78

0.57

0.94

0.49

0.09

0.93

Collateral ligament bowing

0.96

0.58

0.91

1.00

0.11

1.00

Collateral ligament edema

0.98

0.70

0.94

0.95

0.23

0.99

Parameniscal cyst

1.00

0.09

1.00

1.00

0.23

0.61

Parameniscal soft tissue edema

0.97

0.44

0.91

0.59

0.23

0.58

Perivascular bone marrow edema

0.95

0.22

0.97

0.99

0.09

0.95

Effusion

0.77

0.95

0.21

0.37

0.80

0.08

Linear subchondral edema

0.99

0.67

0.97

0.95

0.89

0.99

Adapted from Bergin D, Hochberg H, Zoga AC, etal: Indirect soft-tissue and osseous signs on knee MRI of surgically proven meniscal tears.
AJR Am J Roentgenol 191:8692, 2008. Statistics provided are an average of Reader 1 and Reader 2 values.

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109

Figure 8-4. A through C, Secondary signs of meniscal tear: parameniscal cyst. Coronal (A), sagittal (B), and axial (C) fluid-sensitive
sequences depict a large parameniscal cyst (arrows) emanating from an underlying lateral meniscal tear.

the meniscal root are also more likely to result in substantial

meniscal extrusion. Identifying meniscal extrusion is important, not only in the detection of meniscal tear, but also
because it is strongly associated with the development of
osteoarthritis.3,13

Errors in Interpretation

Figure 8-5. Secondary signs of meniscal tear: collateral ligament

edema. Coronal T2-weighted fat-suppressed image shows medial
collateral ligament bowing and edema (arrow) related to underlying medial meniscal tear.

with the lateral collateral ligament and the lateral meniscus.

Periarticular bone marrow edema can be seen with trauma
and osteoarthritis. However, in the setting of meniscal tear,
linear subchondral bone marrow edema is located directly
adjacent to the meniscus and probably represents hyperemia
at the junction of the bony cortex, cartilage, and meniscus
(Fig. 8-6). These secondary signs can help guide attention to
the meniscus on MRI and can increase confidence when
primary diagnostic criteria are equivocal.1
Meniscal extrusion can also be used as a secondary sign of
meniscal tear. It is defined as extension of the peripheral
meniscus past the tibial margin, and it results from a tear that
destabilizes the circumferential collagen fibers of the meniscus and allows it to expand in a radial direction (Fig. 8-7).
Major meniscal extrusion (>3mm) is more highly associated
with extensive tears, advanced meniscal degeneration,
complex tears, and large radial tears. Tears that extend into

Some normal variants may cause confusion in the diagnosis

of meniscal tears. For instance, the anterior horn of the
lateral meniscus can have a speckled appearance with foci of
increased signal. This may be related to blending of the fibers
of the anterior cruciate ligament with the anterior horn, or
splaying of the fibers of the meniscus at its attachment.11 This
abnormal signal should not be mistaken for a tear or degeneration (Fig. 8-8).
Meniscal flounce is a rare normal variant of the medial
meniscus in which there is an undulating appearance of the
inner margin, possibly related to ligamentous laxity (Fig.
8-9). This buckling along the free edge may be confused for
a meniscal tear, but is not said to increase the risk of tearing.
Its prevalence is approximately 0.2%.11
The meniscofemoral ligaments of Wrisberg and Humphrey
connect the posterior horn of the lateral meniscus to the
lateral aspect of the medial femoral condyle. The ligament
can divide and course anterior to the posterior cruciate ligament named the ligament of Humphrey, or posterior to the
posterior cruciate ligament named the ligament of Wrisberg
(Fig. 8-10). The ligaments of Humphrey and Wrisberg are
noted in approximately one third of cases. If soft tissue or
fluid is interposed between the origin of the meniscofemoral
ligament and the posterior horn of the lateral meniscus, this
interface can be misinterpreted as a meniscal tear. Care must
be taken to follow the ligament over several successive images
while avoiding this pitfall.15
The transverse intermeniscal ligament courses horizontally between the anterior horns of the medial and lateral
menisci, in front of the anterior cruciate ligament. The interface between the ligament and the anterior meniscal horns
can also be confused for a tear.15
The popliteus tendon travels superiorly from its muscle
belly in an oblique, intra-articular course, separating the
lateral meniscus from the joint capsule, to insert on the

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SECTION 2 Imaging of the Knee

Figure 8-6. A through B, Secondary signs of meniscal tear: subchondral edema. Sagittal T2-weighted fat-suppressed image (A) demonstrates linear subchondral bone marrow edema (arrow) adjacent to the posterior horn of the medial meniscus, which contains
surfacing signal consistent with tear. Coronal T2-weighted fat-suppressed image in a different patient (B) demonstrates cartilage loss
in the medial compartment with underlying bone marrow edema (arrow), findings commonly seen in association with a meniscal tear.

Figure 8-7. A and B, Secondary signs of meniscal tear: meniscal extrusion. Coronal T2-weighted fat-suppressed images depict extrusion
of the periphery of the medial meniscus (arrow in A) beyond the periphery of the tibial margin. Major meniscal extrusion, demarcated
by lines in (B), is classified as >3mm; this finding has a high association with complex, radial, or root tear of the associated
meniscus.

popliteal groove along the lateral aspect of the lateral femoral

condyle. The popliteal bursa is the opening created by
the fascicles of the lateral meniscus, which allow the popliteal
tendon to course from its muscle belly into its intraarticular location, and finally to insert on the femur. The
medial margin of the popliteal hiatus is the body of the lateral
meniscus (Fig. 8-11). Fluid within the popliteus tendon
sheath or the popliteal hiatus may be mistaken for a meniscal
tear.7,23
A meniscal contusion occurs during an acute traumatic
event, typically described with an acute anterior cruciate
ligament disruption. The meniscus is compressed between the
femur and the tibia, becomes contused, and demonstrates
altered signal on MRI. The increased signal within the contused meniscus is more likely to be amorphous in shape, will

not extend to the articular surface, and may be accompanied

by a bone bruise. This may simulate a meniscal tear and result
in a false-positive MRI interpretation.11
Magic angle phenomenon describes the artifact that
occurs when collagen fibers are oriented at 55 degrees relative
to the main magnetic field on short TE images. This artifact
causes falsely increased signal intensity and can imitate a
meniscal tear. This is particularly a dilemma in the posterior
horn of the lateral meniscus as it angles upward from its root
to the insertion on the tibia behind the intercondylar
eminence.6
Chondrocalcinosis within the fibrocartilage of the meniscus can cause a false-positive interpretation for tear. Chondrocalcinosis results in increased signal on proton density and
T1-weighted images, which can be confused with a meniscal

CHAPTER 8 Internal Derangements: Menisci and Cartilage

Figure 8-8. Pitfall for meniscal tear: normal intrameniscal signal.

Sagittal proton density image shows fibers of the anterior horn
of the lateral meniscus spreading apart at the root attachment
(arrow). This creates a normal speckled pattern and should not
be confused for a meniscal tear.

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Figure 8-9. Pitfall for meniscal tear: meniscal flounce. Sagittal

fluid-sensitive sequence demonstrates buckling of the meniscal
body (lateral meniscus pictured), referred to as a meniscal
flounce, a normal finding.

Figure 8-10. A through D, Pitfall for meniscal tear: meniscofemoral ligament. Consecutive sagittal proton density images show the ligament of Wrisberg (arrows) coursing from the posterior horn of the lateral meniscus, posterior to the posterior cruciate ligament (PCL),
inserting onto the lateral aspect of the medial femoral condyle; the ligament is seen on magnetic resonance imaging (MRI) in approximately one third of individuals. A similar structure, the ligament of Humphrey, is also seen in about one third of individuals and courses
anterior to the PCL. The point of attachment on the meniscus can simulate a tear on MRI.

Figure 8-11. A through D, Pitfall for meniscal tear: popliteus tendon. Consecutive coronal T2-weighted fat-suppressed images show
the popliteus tendon (arrows) as it originates from the lateral femoral condyle and courses posterolaterally through the popliteal hiatus
and inferiorly past the tibial plateau. As the tendon passes by the lateral meniscus, the intervening fluid can be misinterpreted for
meniscal tear.

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SECTION 2 Imaging of the Knee

Figure 8-12. A and B, Pitfall for meniscal tear: chondrocalcinosis. Frontal radiograph (A) shows lateral meniscal calcification (arrow)
representing calcium pyrophosphate crystal deposition. Coronal T1-weighted image (B) shows increased lateral meniscal signal corresponding to chondrocalcinosis seen on radiographs. This can simulate a meniscal tear.

Figure 8-13. A and B, Discoid meniscus. Three consecutive sagittal proton density images (A) suggest discoid morphology of the lateral
meniscus, with continuity of the anterior and posterior horns on three consecutive sagittal images. Coronal T2-weighted fat-suppressed
image (B) through the midpoint of the knee shows a large, pancake-like lateral meniscus extending centrally, consistent with discoid
morphology.

tear.11 Correlation with radiographs may help to detect and

confirm the presence of chondrocalcinosis within the meniscus (Fig. 8-12).
Some authors propose that a delay between MRI diagnosis
of meniscal tear and arthroscopy may allow for spontaneous
healing.17 When the tear is not identified at surgery, it is
documented as a false positive. Others report that healed or
surgically repaired meniscal tears may have persistent signal
that extends to the articular surface and can be mistaken for
a new meniscal tear or retear. Some meniscal tears are more
difficult to visualize at arthroscopy, particularly along the
inferior surface of the medial meniscus.7 If these tears are not
documented by arthroscopy, which is the gold standard, then
they are also reported as false positive.

Other Meniscal Disorders

Discoid meniscus occurs almost exclusively in the lateral
meniscus with an incidence of approximately 1% in the
general population. Discoid morphology is defined by continuity of the anterior and posterior horns on three or more
consecutive sagittal images. It also can be diagnosed on
coronal images, if the inner margin of the meniscus courses
under or extends past the apex of the femoral condyle (Fig.
8-13). Some propose that a transverse measurement greater
than 15mm, or more than 20% of the tibial width on axial
images, can be used to diagnose discoid meniscus. Discoid
meniscus can be categorized into three types according to its
peripheral attachments. The type that is most commonly
symptomatic is the Wrisberg type, which lacks posterior

CHAPTER 8 Internal Derangements: Menisci and Cartilage

113

Figure 8-14. A and B, Meniscal ossicle. Coronal T1- (A) and T2-weighted fat-suppressed (B) images show ossification (arrows) of the
posterior root of the medial meniscus, following the signal characteristics of bone marrow on all imaging sequences.

capsular attachments. Discoid menisci are believed to be at

increased risk for tear owing to increased mechanical stresses
and hypermobility. Medial discoid menisci have been
reported, but are rare. The incidence of bilateral lateral
discoid menisci has been reported as high as 20%.12
Meniscal ossicles are rare and are most commonly seen in
young men, with a reported prevalence of 0.15%. The origin
of the meniscal ossicle is unknown and is hypothesized to be
developmental or related to previous trauma, representing a
form of heterotopic ossification. Meniscal ossicles are most
commonly found in the posterior horn of the medial meniscus
near the root attachment, following the signal characteristics
of bone marrow on all imaging sequences (Fig. 8-14). Meniscal ossicles may be asymptomatic or may present with
functional impairment and pain. Therapy is guided by the
patients symptoms. Care must be taken not to mistake a
meniscal ossicle for an intra-articular body, an avulsion fracture, or even chondrocalcinosis. The diagnosis can be made
radiographically, with computed tomography (CT), or on
MRI.14

Types of Meniscal Tears

Figure 8-15. Meniscal tear. Sagittal proton density image depicts

a longitudinal oblique tear, with surfacing signal to the inferior
margin of the posterior horn of the medial meniscus (arrow).

Meniscal tears are described according to morphology, location, orientation, and extent. Location and extent are
described in reference to the anterior horn, body, and posterior horn. Orientation is described as longitudinal (i.e., along
the circumference of the meniscus, paralleling the central
meniscal fibers) or radial (i.e., perpendicular to the circumference, crossing through the central fibers). Longitudinal tears
can be horizontal (separating the meniscus into top and
bottom portions), oblique, or vertical. Vertical longitudinal
tears commonly lead to fragment displacement and buckethandle configuration. Radial tears can be straight or curved
(parrot-beak configuration); parrot-beak tears can result in
displaced flaps. Tears with variegated type are referred to as
complex tears. Tears should also be described as mainly
involving the central avascular portion or the peripheral vascularized portion. Small tears of the inner margin or free edge
are also described; these tears may not be mechanically significant. Some types of tears are more mechanically

significant, including tears involving the root attachments,

radial tears, complex tears, and tears with displaced flaps.
Tears with meniscal extrusion greater than 3mm from the
tibial margin are associated with more rapid compartmental
cartilage loss and can predispose susceptible patients (i.e.,
those with osteopenia and lack of buttressing from underlying
osteoarthritis) to subchondral insufficiency fracture.
Oblique or horizontal tears are most commonly degenerative, often extend to the inferior articular surface, and divide
the meniscus into superior and inferior fragments (Fig. 8-15).
These tears are typically stable, although an oblique tear
extending to the undersurface can lead to development of a
flap tear extending from the posterior horn, with the fragment displaced inferior to the meniscal body, in the meniscotibial recess. Frequently, this morphologic pattern of tearing
occurs in the posterior horn of the medial meniscus.

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SECTION 2 Imaging of the Knee

Figure 8-16. A and B, Bucket-handle type of meniscal tear. Coronal and sagittal T2-weighted fat-suppressed images show typical findings. The coronal image (A) demonstrates truncation of the body of the medial meniscus (arrowhead); the flipped fragment (arrow) is
displaced centrally. The sagittal image (B) shows the double PCL sign, with the flipped meniscal fragment (arrow) located beneath the
posterior cruciate ligament (arrowheads).

Figure 8-17. A through D, Radial tear and parrot-beak meniscal tears. Coronal (A) and axial (B) T2-weighted fat-suppressed images
show a notch in the inner margin of the posterior horn medial meniscus representing a small radial tear, extending vertically perpendicular to the meniscal circumference. Coronal (C) and axial (D) T2-weighted fat-suppressed images of a different patient show an
obliquely oriented radial tear with a shape resembling a parrots beak (arrows).

If a vertical longitudinal tear extends to involve the anterior horn, body, and posterior horn, the inner fragment may
displace centrally into the intercondylar notch, creating a
bucket-handletype tear (Fig. 8-16). On sagittal imaging, the
displaced fragment may be seen below the posterior cruciate
ligament, creating the double PCL sign (this occurs only in
medial bucket-handle tears; lateral fragments are blocked by
the intact anterior cruciate ligament). Approximately 95% of
bucket-handle tears involve the medial meniscus and are
detected by noting an abnormal meniscal size or meniscal
truncation. A bucket-handle tear can be mimicked by a torn
anterior cruciate ligament or an intra-articular body. Care
should be taken not to confuse postsurgical truncation related
to dbridement from a meniscal tear with displaced fragment.
A radial tear is a type of vertical tear that occurs along the
inner margin of the meniscus, perpendicular to the circumference of the meniscus (Fig. 8-17). On sagittal and coronal
images, these tears result in a blunted appearance of the
normal triangular morphology of the meniscus. Radial tears
may be seen only on one slicea noted exception to the
two-slice rule. A parrot-beak tear has a radial tear component, which then extends along the longitudinal axis of the

meniscus (curved radial tear). When scrolling through adjacent images, this type of tear will look as though it migrates
through the meniscal substance.
A peripheral tear occurs in the outer one third of the
meniscus, the area known as the red zone, in reference to its
vascular supply (Fig. 8-18). A peripheral tear is amenable to
meniscal repair because of the increased vascularity. Alternatively, some surgeons may wait to repair the meniscus, given
the possibility that the tear may heal on its own. Care should
be taken not to miss these types of tears, which can be difficult to detect, as they tend to blend with the hyperintense
perimeniscal tissues and/or joint recesses.
Meniscal root attachments prevent meniscal displacement
in a radial direction and act as primary resistance to hoop
strain during axial load bearing. Meniscal root tears are often
missed and can lead to accelerated osteoarthritis. A root tear
should be suspected if, while looking at sagittal images, it
appears that the posterior horn has disappeared; these tears
are typically radial tears. Meniscal root tears occur medially
more often than laterally and are often associated with extrusion and the development of degenerative joint disease
(Fig. 8-19).

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Figure 8-18. A and B, Peripheral meniscal tear. Sagittal proton density (A) and T2-weighted fat-suppressed images (B) show vertical
signal extending through the outer margin of the posterior horn medial meniscus (arrows).

Figure 8-19. A through C, Meniscal root tear. Sagittal (A), coronal (B), and axial (C) T2-weighted fat-suppressed images show fluid
signal extending through the posterior root attachment of the medial meniscus (arrows). Root tears are often radial type, as seen in
this example; resultant meniscal destabilization causes extrusion and is strongly associated with subsequent cartilage loss.

A complex tear is a meniscal tear with more than one

cleavage plane. Frequently, the tear extends to both the superior and inferior articular surfaces. These tears are more likely
to be unstable, lead to meniscal extrusion, and progress to
osteoarthritis.
A flap tear is a meniscal tear that results in an isolated
fragment, which becomes displaced (Fig. 8-20); flaps commonly become displaced into the meniscotibial or meniscofemoral recess. If the meniscus appears diminutive and there
has been no history of meniscectomy, care must be taken to
evaluate for a flap tear with a displaced meniscal fragment.
Meniscal fragments can also flip anteriorly, creating an
enlarged appearance of the anterior horn, or the entire meniscal horn can flip centrally, often posterior to the posterior
cruciate ligament (Fig. 8-21).

Meniscal Tear Stability

An unstable meniscal tear is defined as a tear in which a
fragment of the meniscus can be displaced by a probe into

the femorotibial joint at the time of arthroscopy. Unstable

tears lead to meniscal extrusion and accelerated osteoarthritis. Therefore, predicting the stability of a meniscal lesion on
MRI helps guide management of the tear, pointing toward
spontaneous healing, repair, or resection. The following MRI
criteria have been used to evaluate unstable meniscal lesions
and have been compared with findings at arthroscopy:
1. A displaced meniscal fragment is visible on MRI.
2. A lesion is visible on more than two 4-mm-thick sagittal
and on three 3-mm-thick coronal images.
3. More than one lesion pattern or more than one cleavage
plane is present within the meniscus.
4. Fluid signal is present within the meniscus on T2-weighted
images.
These MRI criteria for unstable meniscal lesions were
found to have high specificity and positive predictive value
when compared with findings at arthroscopy. This was important because it meant that unstable meniscal tears could be
identified by MRI, and therefore patients who would benefit
from arthroscopy could be delineated.21

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SECTION 2 Imaging of the Knee

Figure 8-20. A through C, Meniscal flap tears. Axial (A) and sagittal (B) T2-weighted fat-suppressed images show a parrot-beaktype
tear at the junction of the body and the posterior horn of the medial meniscus (arrows) with displacement of the inner margin fragment. Coronal T2-weighted fat-suppressed image (C) of a different patient shows a meniscal fragment (arrowhead) flipped under the
body of the medial meniscus, into the meniscotibial recess. Note underlying reactive bone marrow edema in the medial tibial plateau
(arrow).

Figure 8-21. Anteriorly flipped meniscal fragment. Sagittal

T2-weighted fat-suppressed image though the lateral compartment shows that a large meniscal fragment (arrow) originating
from the posterior horn has flipped anteriorly and is positioned
next to the native anterior horn. This can block full range of
motion on extension.

Figure 8-22. Sagittal T1-weighted fat-suppressed image from an

indirect magnetic resonance arthrogram (delayed imaging following an intravenous dose of gadolinium contrast) demonstrates contrast within the posterior horn of the medial meniscus
(arrow) at the site of prior dbridement, consistent with recurrent
tear.

Postoperative Meniscus

contrast will dissect into a residual or recurrent meniscal tear

in the postoperative patient, highlighting the abnormality.
With indirect MR arthrography, gadolinium contrast is
administered intravenously. After an appropriate delay, the
knee joint is imaged. A residual or recurrent meniscal tear
should enhance beyond adjacent meniscal tissue, accentuating the abnormality (Fig. 8-22). Unfortunately, granulation
tissue in a healed meniscus can also enhance, confounding
the importance of the finding. Studies comparing diagnostic
accuracy between direct and indirect arthrography found no
significant difference. CT arthrography has also been suggested as useful for evaluation of the postoperative meniscus
(Fig. 8-23). CT is insensitive to the internal degenerative
signal that causes confusion on MRI in the postoperative

After meniscal repair or meniscal healing, MRI findings of

surfacing signal abnormality may persist and may appear no
different from the tear initially noted on preoperative imaging.
For this reason, standard MRI diagnostic criteria for meniscal
tears cannot be applied to the postoperative or healed meniscus. This creates a diagnostic dilemma in the postoperative
patient with recurrent or residual symptoms.
Magnetic resonance (MR) arthrography has been promoted for assessment of the postoperative meniscus. With
direct MR arthrography, dilute gadolinium contrast is placed
directly into the joint under fluoroscopic guidance. The joint
is distended by the contrast. Theoretically, intra-articular

CHAPTER 8 Internal Derangements: Menisci and Cartilage

meniscus, and contrast entering the meniscus is specific for

retear.4
Noncontrast MRI can also evaluate for a retear in the
postoperative meniscus. In a symptomatic patient with clinical suspicion for meniscal retear, the fluid-sensitive sequence
is most specific for diagnosis. Fluid signal within the meniscus
tracking to the articular surface is highly predictive of retear.
This represents free fluid tracking through the meniscal tear
and simulates the arthrographic effects of contrast insinuating into the tear.4 Secondary signs of meniscal tear, including
associated subchondral bone marrow edema, parameniscal

117

cyst, and adjacent collateral ligament edema, may also prove

to be important.

Spontaneous Osteonecrosis
of the Knee (SONK)
Spontaneous osteonecrosis of the knee, also referred to as
SONK, is an outdated term that describes subchondral insufficiency fractures typically found along the weight-bearing
aspect of the medial femoral condyle in middle-aged to elderly
patients, more commonly females. The entity can also involve
the lateral femoral condyle or the tibial plateau and is believed
to be related to altered biomechanics and weight bearing
following a meniscal tear or meniscal surgery. On MRI, the
subchondral fracture line is hypointense on T1- and
T2-weighted images with extensive adjacent bone marrow
edema. Bone marrow edema may even extend to the femoral
notch (Fig. 8-24). Following intravenous gadolinium administration, the subchondral fracture line will not enhance.
Subchondral insufficiency fractures are usually treated
conservatively. However, if treatment is not effective or is
delayed, the insufficiency fracture can progress to osteonecrosis and articular collapse, requiring surgery. In later stages, the
subchondral fracture line becomes less visible, bone marrow
edema decreases, and findings of osteonecrosis and osteoarthritis dominate.

Cartilage
Cartilage and Osteochondral Injuries

Figure 8-23. Meniscal tear on computed tomography (CT) arthrogram. Coronal reconstruction CT image through the posterior
aspect of the knee following intra-articular injection of contrast in
a patient with prior meniscal surgery and recurrent knee pain
shows contrast dissecting through a large radial tear in the posterior horn of the medial meniscus (arrow), near its posterior root
attachment.

Hyaline cartilage covers the articular surface of the knee joint

and is composed of chondrocytes surrounded by a medium of
collagen, proteoglycans, and electrolytes. Hyaline cartilage
acts to aid in resistance against compressive and shearing
forces, predominantly by dissipating the forces to the menisci
and subchondral bone.19 Because of the prevalence of degenerative osteoarthritis, imaging of hyaline cartilage has become
an important focus of diagnostic radiology research.

Figure 8-24. A through C, Spontaneous osteonecrosis of the knee (SONK), also known as a subchondral insufficiency fracture (SIFK).
Coronal T2-weighted fat-suppressed image (A) shows the classic magnetic resonance features, with diffuse bone marrow edema in
the medial femoral condyle and a low signal crescent in the subchondral bone (arrow) representing the fracture line. Note associated
meniscal extrusion that is often seen with this phenomenon. Surrounding soft tissue edema related to hyperemia is also commonly
seen. The fracture can progress to osteonecrosis. Coronal (B) and sagittal (C) T2-weighted fat-suppressed images of a different patient
demonstrate articular collapse at the site of subchondral fracture (arrows), with delamination of the overlying hyaline cartilage.

118

SECTION 2 Imaging of the Knee

Figure 8-25. A through D, Normal articular cartilage. Normal cartilage is demonstrated on coronal T1 (A), sagittal proton density
(B), axial T2-weighted fat-suppressed (C), and sagittal T2-weighted fat-suppressed (D) images. Articular cartilage has intermediate signal
on T1- and T2-weighted images; on most sequences, fat suppression results in higher relative cartilage signal. Achieving high resolution and a pronounced difference in brightness of cartilage and joint fluid is essential for imaging cartilage abnormalities. Note poor
contrast between cartilage and joint fluid on the T1-weighted image (A).

MRI of Hyaline Cartilage

To adequately image hyaline cartilage in the knee, adequate
differences in signal intensity (contrast) must be evident
between joint fluid, hyaline cartilage, and subchondral bone.
Additionally, spatial resolution must be optimized, allowing
for differentiation between cartilage thinning, fissuring, and
partial-thickness and full-thickness defects.
No universal MRI sequence has been dedicated for hyaline
cartilage imaging. Proton density and T2-weighted fast spin
echo sequences with fat suppression provide sufficient contrast between higher signal joint fluid and intermediate signal
cartilage to detect chondral abnormalities. Both proton
density and T2-weighted fast spin echo sequences produce
high signal-to-noise ratio images with relatively short acquisition times. Short T1 inversion recovery (STIR) images may
also provide sufficient contrast resolution to evaluate for
chondral abnormalities, but intrinsically have lower signalto-noise ratio and spatial resolution. Two- or threedimensional (2D or 3D) gradient imaging sequences can
improve resolution and can more accurately evaluate the
superficial surface of the cartilage; however, these sequences
generally require a longer acquisition time, are limited for use
in evaluation of deeper cartilage layers, and are more susceptible to imaging artifacts.19 MRI diagnostic capabilities in
low-grade cartilage lesions are limited by contrast and spatial
resolution, partial volume averaging, and artifact.
Normal articular cartilage has a homogeneous or laminar
appearance with a smooth surface contour. Articular cartilage
has intermediate signal on both T1- and T2-weighted images
(Fig. 8-25). Fat-suppression techniques can be used on any
sequence and have the advantage of increasing apparent
signal of the hyaline cartilage relative to other tissues (i.e.,
cartilage appears bright on fat-suppressed images, regardless
of the sequence used).
Chondral abnormalities are diagnosed on MRI by recognizing a contour defect within the cartilage, focal thinning
compared with the thickness of the adjacent cartilage, and/
or signal alteration within the cartilage (Figs. 8-26 through
8-30). A secondary sign of cartilage defect includes underlying bone marrow edema, as manifested by increased signal in
the subchondral bone on fat-suppressed proton density and
T2-weighted images. Subchondral bone marrow edema is a
nonspecific finding that may be seen with acute injury (bone
contusion or bruise, fracture), mechanical disturbance such

Figure 8-26. Low-grade chondromalacia. Axial T2-weighted fatsuppressed image shows swollen, T2 hyperintense cartilage
(arrow) along the median ridge of the patella.

as stress response or overlying meniscal tear, and many other

conditions, including metabolic and neoplastic lesions.
However, a flame-shaped or rounded focus of marrow edema
in the subchondral bone should initiate a search for overlying
hyaline cartilage abnormality.
Cartilage damage can be related to acute trauma, prolonged and repetitive stress, and degeneration. Numerous
classifications have been proposed to grade cartilage lesions
based largely on arthroscopic findings, and less so on MRI
findings. These classification systems describe articular cartilage damage ranging from swelling and signal heterogeneity
to fissuring, ulceration, partial-thickness defects, and fullthickness defects with exposure of the subchondral bone.
The Outerbridge scale classifies cartilage abnormalities
based on arthroscopic findings. Grade I includes softening or
swelling of the articular cartilage, Grade II describes cartilage
fragmentation and fissuring less than 1.5cm in diameter,
Grade III describes cartilage fragmentation and fissuring
greater than 1.5cm in diameter, and Grade IV involves

CHAPTER 8 Internal Derangements: Menisci and Cartilage

cartilage erosion to bone.18 The International Cartilage

Repair Society has adopted the classification system described
by Yulish and associates. Grade 0 represents normal cartilage,
Grade 1 describes increased T2 signal within the cartilage,
Grade 2 refers to a partial-thickness defect less than 50% of
normal cartilage thickness, Grade 3 represents a partialthickness defect greater than 50% of normal cartilage thickness, and Grade 4 describes a full-thickness defect.16 In the
Noyes system, Grade 1 depicts an intact cartilage surface,
Grade 2A reflects cartilage damage with less than 50% cartilage thickness involved, Grade 2B cartilage defects involve
greater than half of the cartilage thickness, and Grade 3
represents full-thickness cartilage defects with exposed

119

subchondral bone (3A cortical surface is intact, 3B cortical

surface shows cavitation) (Table 8-2).
Aside from grading cartilage loss, assessing the location,
size, and morphology of the cartilage defect is also important.
Chondral injuries in weight-bearing areas have a worse
prognosis and different treatment implications than those in
nonweight-bearing areas. Traumatic chondral injuries are
usually focal and may have acute margins with adjacent
shoulders. They may be partial thickness or full thickness and
can shear off from the cortex, resulting in an intra-articular
body.22
In osteoarthritis, the cartilage thins particularly along
weight-bearing aspects and degenerates with fraying, fissuring, ulceration, and sometimes delaminating defects. Accompanying osteophyte formation, subchondral cystic change,

Table 8-2 Chondral Injury Classifications

Figure 8-27. Partial-thickness cartilage defect. Axial T2-weighted

fat-suppressed image demonstrates diffuse patellar cartilage
thinning with focal partial-thickness cartilage loss at the lateral
facet (arrow), accounting for <50% of the normal cartilage
thickness.

Outerbridge

ICRS

Noyes

Grade I: softening
and swelling of
cartilage

Grade 0: normal
cartilage

Grade 1: intact
cartilage surface

Grade II: cartilage

fragmentation and
fissuring <1.5cm
diameter

Grade 1:
increased T2
signal in the
cartilage

Grade 2A: cartilage

surface damaged
with <50% thickness
involved

Grade III:
fragmentation and
fissuring >1.5cm
diameter

Grade 2: partialthickness defect

<50% of normal
cartilage thickness

Grade 2B: cartilage

defects involve >50%
cartilage thickness

Grade IV: cartilage

erosion to bone

Grade 3: partialthickness defect

>50% of normal
cartilage thickness

Grade 3: bone
exposed (3A cortical
surface intact, 3B
cortical surface
cavitation)

Grade 4: fullthickness defect

ICRS, International Cartilage Repair Society.

Figure 8-28. A and B, Full-thickness cartilage fissuring. Axial T2-weighted fat-suppressed image (A) depicts a small fissure at the medial
patellar facet (arrow). Axial T2-weighted fat-suppressed image of a different patient (B) shows a broader area of cartilage surface
irregularity at the lateral facet with a full-thickness fissure (arrow).

120

SECTION 2 Imaging of the Knee

bone marrow edema, and sclerosis may occur. Several studies

have demonstrated that meniscal root tears, large radial
meniscal tears, and severe meniscal degeneration are strongly
associated with major meniscal extrusion and may precede or
even accelerate the development of osteoarthritis with cartilage loss.22
Inflammatory arthritides result in diffuse, uniform cartilage
thinning throughout the joint, with uniform joint space narrowing. Focal cartilage defects are not typical. However, in
areas of inflammatory pannus, focal cartilage and bony erosions may be found. Significant osteophyte formation should
not occur.22

Osteochondral Lesions
The term osteochondral lesion is used to describe a spectrum
of disease from traumatic osteochondral injury to chronic
osteochondritis dissecans. Lesions may arise from forces
applied to the chondral surface in a single traumatic event or
over time as the result of repeated minor injury. Damage to
the underlying subchondral bone ensues. The bone may
become necrotic and collapse. If the cartilage surface is
damaged, fluid can extend from the joint into the bone and
the fragment can separate, eventually detaching and forming
a loose body. Alternatively, especially if the overlying cartilage remains intact, the underlying bone can heal. Overlying
cartilage can itself delaminate and become displaced as an
intra-articular body, or it may degenerate and become thinned
and fissured. Most commonly, osteochondral lesions are
encountered in the talus, femoral condyles, and elbow.

Traumatic Osteochondral Lesions

A traumatic osteochondral lesion occurs when shearing, compressive, or rotational forces are transmitted between two
articular surfaces, resulting in a chondral or subchondral fracture (Fig. 8-31). A cartilage flap or an osteochondral fragment
may form, depending on the depth of the fracture line. This
injury is typically associated with tenderness, a joint effusion,
and sometimes even hemarthrosis. Elevated intra-articular
pressure is thought to force synovial fluid into the cartilage flap
or beneath the osteochondral fragment, resulting in resorption
of the subchondral bone and cystic change. Sometimes the
cartilage flap or osteochondral fragment dissociates from the
underlying bone, resulting in an intra-articular body.16

Osteochondritis Dissecans
Figure 8-29. Focal full-thickness defect. Coronal T2-weighted fatsuppressed image shows a focal full-thickness cartilage defect
(arrow) along the lateral femoral condyle. Reactive underlying
subchondral bone marrow edema is evident.

Osteochondritis dissecans (OCD) is a somewhat outdated

term, although it is still in common use; a better term is
osteochondral lesion. Nevertheless, the term OCD typically
refers to an osteochondral lesion that is discovered

Figure 8-30. A and B, Cartilage delamination. Sagittal T2-weighted fat-suppressed images demonstrate a broad area of full-thickness
cartilage loss from the posterior aspect of the medial femoral condyle (arrows in A). The cartilage has delaminated from the femoral
condyle and is seen displaced into the posterior joint space (arrow in B).

CHAPTER 8 Internal Derangements: Menisci and Cartilage

121

Figure 8-31. A through C, Osteochondral impaction injury. Sagittal T2-weighted fat-suppressed (A), coronal T2-weighted fat-suppressed
(B), and coronal T1-weighted (C) images show an osteochondral impaction injury along the lateral femoral condyle (arrows) consistent
with a pivot shift mechanism of injury.

Figure 8-32. A through C, Osteochondral lesion. Coronal T1-weighted (A), coronal T2-weighted fat-suppressed (B), and sagittal
T2-weighted fat-suppressed (C) images show a chronic osteochondral lesion (arrows) along the lateral aspect of the medial femoral
condyle. This is also referred to as osteochondritis dissecans. Underlying cystic change seen in (B) suggests instability; black signal in
(A) in the subchondral bone suggests underlying necrosis.

incidentally and is presumed to represent a chronic injury.

Classic OCD is most commonly seen in young patients
between 10 and 20 years of age. The idiopathic variety of
OCD often occurs in the lateral aspect of the medial femoral
condyle, along the nonweight-bearing aspect near the intercondylar notch, possibly related to microtrauma between the
tibial spine and the medial femoral condyle during internal
rotation of the tibia. Repetitive microinjuries are thought to
disrupt blood supply to the subchondral bone, sometimes
resulting in osteonecrosis and progressing to an osteochondral lesion. The natural progression of stable OCD (i.e., with
intact overlying cartilage) is spontaneous healing. However,
if the lesion is painful and unstable, surgery is usually
indicated.
MRI should be performed to accurately characterize OCD,
to evaluate size and location, and to determine the stability
of the lesion (Fig. 8-32). The osteonecrotic fragment has low
signal intensity on T1- and T2-weighted images. Measurement is generally performed using T1-weighted images. Surrounding bone marrow edema is variable and may represent
healing response or irritation from lesion instability, so this
finding is nonspecific; however, it is often the case that the

more bone marrow edema is present, the more painful the

lesion is. An unstable lesion is identified by one or more of
the following findings on T2-weighted fat-suppressed images
or STIR images: (1) linear high signal intensity surrounding
the osteochondral fragment, (2) cystic change interposed
between the osteochondral fragment and normal bone, or
(3) overlying cartilage defect or fissuring.5 Intra-articular
gadolinium may dissect beneath the osteochondral fragment,
also indicating lesion instability.
OCD was initially graded by Berndt and Harty into four
stages, with the first two stages indicating lesion stability, and
the last two stages signifying instability. Stage 1 demonstrates
no discontinuity between the osteochondral lesion and surrounding bone, Stage 2 describes a partially detached but
stable osteochondral lesion, Stage 3 refers to a completely
detached osteochondral lesion that is not dislocated, and
Stage 4 represents a completely detached and displaced osteochondral fragment. The Anderson MRI classification of
OCD is more widely used; it was initially created to describe
osteochondral lesions of the talus (OLT), but can be applied
to the knee and other areas. Stage I refers to the presence of
bone marrow edema, Stage IIa describes underlying

122

SECTION 2 Imaging of the Knee

Figure 8-33. A through C, Osteochondral lesion. Coronal T1-weighted (A), coronal T2-weighted fat-suppressed (B), and sagittal
T2-weighted fat-suppressed (C) images demonstrate an unstable osteochondral lesion along the lateral aspect of the medial femoral
condyle. Fluid is interposed between the osteochondral lesion and the normal femoral condyle. The fragment is partially detached.
This corresponds to Anderson stage IV.

subchondral cystic change, Stage IIb refers to a partially

detached osteochondral lesion with bone marrow edema,
Stage III lesions have fluid undermining a nondisplaced and
completely detached osteochondral lesion, and Stage IV
describes a completely detached and displaced osteochondral
fragment (Fig. 8-33). One criticism of this classification is
that bone marrow edema may be present at any stage and
appears to be a nonspecific finding.9,16
A healed osteochondral lesion will not demonstrate fluid
bright signal between the osteochondral fragment and the
host bone. Normal bone marrow fat signal will return to the
osteochondral fragment once it heals. The overlying articular
cartilage may be intact, without contour irregularities, or may
exhibit degeneration, thinning, or fraying.

Recent Advances in MRI of Cartilage

Current MRI of articular cartilage utilizes 2D multislice
acquisitions with small gaps between slices. Three-dimensional
imaging, typically spoiled gradient recalled echo with fat suppression, allows for volumetric image acquisition, producing
high contrast between the signal of cartilage and adjacent
joint fluid. Three-dimensional spoiled gradient recalled
(SPGR) sequence is the standard for evaluating cartilage
volume and thickness, but is limited for use in evaluating
internal cartilage abnormalities (e.g., degeneration, delamination) and other joint pathology.
Driven equilibrium Fourier transform (DEFT) imaging
uses a 90-degree pulse to return magnetization to the z-axis,
and increases signal from tissues with long T1 relaxation
time. This results in high signal synovial fluid and improved
contrast between cartilage and fluid at a short time to repetition (TR). The contrast between cartilage and synovial fluid
with DEFT imaging is superior to that with SPGR, proton
density fast spin echo, and T2-weighted fast spin echo
images.10
Balanced steady-state free precession (SSFP) is also known
as trueFISP (true fast imaging with steady-state precession,
Siemens Healthcare, Malvern, Pa), FIESTA (fast imaging
employing steady-state acquisition, GE Healthcare, Buckinghamshire, UK), or BFFE (balanced fast-field echo imaging,

Philips Healthcare, Andover, Mass), depending on the MRI

scanner manufacturer. Images are 3D volumetric acquisitions,
synovial fluid is hyperintense, and tissue contrast is sufficient
for evaluation of cartilage and for imaging internal
derangement.10
T2 relaxation time mapping is based on the knowledge
that T1 and T2 relaxation times are constant for a given
tissue at specific MRI field strengths. Alteration of relaxation
time within a given tissue may be related to pathology or
introduction of a contrast agent. T2 relaxation time mapping
detects the water content within cartilage, with altered water
content correlating with cartilage damage. A color or gray
scale map depicting the T2 relaxation time is created, illustrating areas of cartilage damage.10
Delayed gadolinium-enhanced MRI of cartilage
(dGEMRIC) refers to the use of Magnevist, or gadopentetate
dimeglumine, in the evaluation of cartilage damage. Magnevist carries a negative ionic charge, which facilitates its
diffusion into cartilage and concentration in areas of
decreased glycosaminoglycan (GAG) content. A T1 map is
created, demonstrating glycosaminoglycan content. Areas of
decreased GAG correspond to damaged cartilage.10
KEY REFERENCES
Bergin D, Hochberg H, Zoga AC, et al: Indirect soft-tissue and osseous signs
on knee MRI of surgically proven meniscal tears. AJR Am J Roentgenol
191:8692, 2008.
Campbell SE, Sanders TG, Morrison WB: MR imaging of meniscal cysts:
incidence, location, and clinical significance. AJR Am J Roentgenol
177:409413, 2001.
Costa CR, Morrison WB, Carrino JA: Medial meniscus extrusion on knee
MRI: is extent associated with severity of degeneration or type of tear?
AJR Am J Roentgenol 183:1723, 2004.
DeSmet AA, Norris MA, Yandow DR, et al: MR diagnosis of meniscal tears
of the knee: importance of high signal in the meniscus that extends to the
surface. AJR Am J Roentgenol 161:101107, 1993.
DeSmet AA, Tuite MJ: Use of the two-slice-touch rule for the MRI diagnosis of meniscal tears. AJR Am J Roentgenol 187:911914, 2006.
Elias I, Jung JW, Raikin SM, et al: Osteochondral lesions of the talus: change
in MRI findings over time in talar lesions without operative intervention
and implications for staging systems. Foot Ankle Int 27:157166, 2006.
Gold GE, Chen CA, Koo S, Hargreaves BA, Bangerter NK: Recent
advances in MRI of articular cartilage. AJR Am J Roentgenol 193:628
638, 2009.


Helms CA: The meniscus: recent advances in MR imaging of the knee. AJR
Am J Roentgenol 179:11151122, 2002.
Kocher MS, Klingele K, Rassman SO: Meniscal disorders: normal, discoid,
and cysts. Orthop Clin North Am 34:329340, 2003.
Lerer DB, Umans HR, Hu MX, Jones MH: The role of meniscal root pathology and radial meniscal tear in medial meniscal extrusion. Skeletal Radiol
33:569574, 2004.
Pope TL, Bloem HL, Beltran J, Morrison WB, Wilson DJ: Imaging of the
musculoskeletal system, ed 1, Philadelphia, 2008, Saunders Elsevier,
pp 567596, 665689.
Rodrguez-Merchn EC, Gmez-Cardero PG: The Outerbridge classification
predicts the need for patellar resurfacing in TKA. Clin Orthop Relat Res
468:12541257, 2010.

CHAPTER 8 Internal Derangements: Menisci and Cartilage

123

Sonin AH, Pensy RA, Mulligan ME, Hatem S: Grading articular

cartilage of the knee using fast spin-echo proton density weighted MR
imaging without fat suppression. AJR Am J Roentgenol 179:11591166,
2002.
Vande Berg BC, Poilvache P, Duchateau F, et al: Lesions of the menisci of
the knee: value of MR imaging criteria for recognition of unstable lesions.
AJR Am J Roentgenol 176:771776, 2001.
Verstraete KL, Almqvist F, Verdonk P, et al: Magnetic resonance imaging of
cartilage and cartilage repair. Clin Radiol 59:674689, 2004.
Full references for this chapter can be found on www.expertconsult.com.

REFERENCES
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2. Campbell SE, Sanders TG, Morrison WB: MR imaging of meniscal
cysts: incidence, location, and clinical significance. AJR Am J Roentgenol 177:409413, 2001.
3. Costa CR, Morrison WB, Carrino JA: Medial meniscus extrusion on
knee MRI: is extent associated with severity of degeneration or type of
tear? AJR Am J Roentgenol 183:1723, 2004.
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AJR Am J Roentgenol 190:2226, 2008.
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tears of the knee: importance of high signal in the meniscus that extends
to the surface. AJR Am J Roentgenol 161:101107, 1993.
8. DeSmet AA, Tuite MJ: Use of the two-slice-touch rule for the MRI
diagnosis of meniscal tears. AJR Am J Roentgenol 187:911914, 2006.
9. Elias I, Jung JW, Raikin SM, et al: Osteochondral lesions of the talus:
change in MRI findings over time in talar lesions without operative
intervention and implications for staging systems. Foot Ankle Int
27:157166, 2006.
10. Gold GE, Chen CA, Koo S, Hargreaves BA, Bangerter NK: Recent
advances in MRI of articular cartilage. AJR Am J Roentgenol 193:628
638, 2009.
11. Helms CA: The meniscus: recent advances in MR imaging of the knee.
AJR Am J Roentgenol 179:11151122, 2002.

CHAPTER 8 Internal Derangements: Menisci and Cartilage 123.e1

12. Kocher MS, Klingele K, Rassman SO: Meniscal disorders: normal,
discoid, and cysts. Orthop Clin North Am 34:329340, 2003.
13. Lerer DB, Umans HR, Hu MX, Jones MH: The role of meniscal root
pathology and radial meniscal tear in medial meniscal extrusion. Skeletal Radiol 33:569574, 2004.
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assessment of meniscal ossicle. Skeletal Radiol 29:481484, 2000.
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Relat Res 468:12541257, 2010.
19. Sonin AH, Pensy RA, Mulligan ME, Hatem S: Grading articular cartilage of the knee using fast spin-echo proton density weighted MR
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