Pitfalls and Pearls in MRI of The Knee

M u s c u l o s k e l e t a l I m a g i n g R ev i ew
Mohankumar et al.
Pitfalls and Pearls in MRI of the Knee
FOCUS ON:
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Musculoskeletal Imaging
Review
Rakesh Mohankumar 1,2

Lawrence M. White1,3
Ali Naraghi1,2
Mohankumar R, White LM, Naraghi A

OBJECTIVE. The purpose of this article is to review the common pitfalls in MRI of the
knee and pearls on how to avoid them.
CONCLUSION. MRI of the knee is highly accurate in evaluation of internal derangements of the knee. However, a variety of potential pitfalls in interpretation of abnormalities
related to the knee have been identified, particularly in evaluation of the menisci, ligaments,
and articular cartilage.
Keywords: knee, ligaments, meniscus, MRI,

postoperative MRI
DOI:10.2214/AJR.14.12969
Received April 4, 2014; accepted after revision
May 7, 2014.
1
Joint Department of Medical Imaging, University Health

Network, Mount Sinai Hospital and Womens College
Hospital, Toronto, ON, Canada.
2
Department of Medical Imaging, University of Toronto,
Toronto Western Hospital, 399 Bathurst St, Toronto, ON
M5T 258, Canada. Address correspondence to
A. Naraghi (ali.naraghi@uhn.ca).
3
Department of Medical Imaging, University of Toronto,
Toronto General Hospital, Toronto, ON, Canada.
AJR 2014; 203:516530

0361803X/14/2033516
American Roentgen Ray Society
516
he knee is the articulation most

commonly assessed for internal
derangement by MRI. A number
of potential pitfalls and sources
of error related to the knee have been described in the MRI literature. Sources of
such pitfalls include areas of normal anatomy, anatomic variants, and technique-related
artifacts masquerading as abnormalities as
well as commonly overlooked abnormalities.
A thorough knowledge of such pitfalls is essential for the radiologist. This article will
review the more commonplace sources of error in MRI of the knee. We will address situations in which normal anatomic variants
can mimic abnormality and evaluate abnormalities that can be overlooked.
Menisci
MRI has sensitivity of 8796% and specificity of 8494% for medial meniscal tears
and sensitivity of 7092% with specificity
of 9198% for diagnosing tears of the lateral meniscus [15]. Identification of meniscal
tears has long been based on two criteria: intrameniscal signal intensity exiting the superior or inferior articular surface of the meniscus on short TE sequences and change in
morphology of the meniscus [6, 7]. Evaluation of menisci on T1-weighted images may
be misleading because it is difficult to distinguish tears from areas of intrameniscal degeneration and the extent of a tear may be
overestimated on T1-weighted imaging.
Normal anatomic interfaces may also
mimic meniscal tears on orthogonal shortTE MRI acquisitions. Examples include the
interface of the junction of the anterior transverse intermeniscal ligament with the anterior horns of the menisci and the interface
between the popliteus tendon and the lateral meniscus at the popliteal hiatus [7]. Small
amounts of fluid may be seen along these
interfaces; however, such signal intensity
changes can be distinguished from meniscal tears by careful delineation of the normal anatomic structures on consecutive MR
images and on orthogonal imaging planes.
The normal anterior horn of the lateral meniscus, close to its tibial root attachment, often shows a speckled or striated appearance,
particularly on short-TE sequences. This appearance is believed to be related to the intimate relationship of the insertions of the
anterior root of the lateral meniscus and the
tibial attachment of the anterior cruciate ligament (ACL), with the collagenous fibers of
the ACL intertwining with the fibrocartilage of the anterior horn of the lateral meniscus. The resultant signal intensity changes
may contact the articular surface, simulating
a meniscal tear [8]. However, isolated tears
of the anterior horn of the lateral meniscus
are relatively rare and account for only 16%
of lateral meniscal tears [9]. Most of these
tears occur more peripherally, adjacent to
the junction of the anterior horn and body of
the lateral meniscus. Circumferential longitudinal extension of signal intensity toward
the body and possible associated parameniscal cysts may be helpful indicators of true
meniscal tears in this location. In contrast,
the anterior root of the medial meniscus has
a more homogeneous MRI appearance. The
AJR:203, September 2014

insertion point of the anterior root of the medial meniscus shows greater variability and
can insert onto the anterior cortex of the tibia
and be mistaken for anterior subluxation or
hypermobility of the medial meniscus [10].
The insertion of the meniscofemoral ligaments to the posterior horn of the lateral
meniscus can be an area of diagnostic challenge. True tears at the junction of the meniscofemoral ligament and the posterior horn
of the lateral meniscus, referred to as the
Wrisberg rip [11], are typically associated
with ACL tears and rotational biomechanics implicated in such injuries. Variability
in insertion of the meniscofemoral ligament
to the posterior horn of the lateral meniscus
can lead to a false diagnosis of a vertical or
oblique tear often referred to as the Wrisberg pseudotear [12, 13]. On average, the
ligament of Wrisberg inserts onto the posterior horn of the lateral meniscus approximately 14-mm lateral to the lateral edge of
the posterior collateral ligament (PCL) [14],
and extension of a cleft between the ligament
of Wrisberg and the posterior horn of the lateral meniscus beyond this is highly suspicious for a tear (Fig. 1).
The medial meniscus has a firmer broader peripheral capsular attachment than the lateral meniscus, typically with lack of fluid at
the meniscocapsular junction. Meniscocapsular separation often occurs in the setting of a
rotational injury with associated cruciate ligament tears. The presence of peripheral perimeniscal fluid and an irregular peripheral
medial meniscal outline are indicators of meniscocapsular injury [15]. Occasionally, small
recesses may be present at the meniscocapsular junction of the posterior horn of the medial
meniscus and these may simulate a meniscocapsular tear. With a recess, such peripheral
fluid signal intensity should not extend all the
way superoinferiorly as opposed to complete
meniscocapsular tears in which clefts of peripheral juxtameniscal fluid signal intensity
extends completely from the superior surface
of the meniscocapsular junction to its inferior surface (Fig. 2). However, false-positive diagnoses of meniscocapsular tears are not rare
and are thought to be related to the propensity
of these tears for healing [16].
The discoid meniscus is another meniscal morphologic variant resulting in a thickened wafer-shaped meniscus with increased
width and coverage of the articular surface
of the joint. Discoid meniscus more commonly involves the lateral meniscus, with a
reported incidence ranging between 1.5%
and 4.6% compared with 0.3% for the medial meniscus [17]. A discoid meniscus is associated with increased incidence of meniscal tears secondary to increased mechanical
stress and hypermobility [18]. Diagnosis of
a tear of a discoid meniscus can occasionally be difficult. Linear increased signal intensity exiting the articular surface is diagnostic of a tear, whereas diffuse signal intensity
to the surface is less predictive (6080%) of
a tear [7]. A rare variant of the discoid lateral meniscus is the Wrisberg variant, in
which the meniscus lacks a posterior capsular attachment to the tibia, with the Wrisberg
meniscofemoral ligament as the sole stabilizer of the posterior horn [19]. On MRI,
the meniscus lacks the normal fascicle attachments onto the posterior horn. These
Wrisberg variant lateral discoid menisci are
unstable and hypermobile, commonly associated with resultant mechanical symptoms
in the articulation, and usually treated surgically. Vacuum phenomenon can simulate a
discoid-type meniscus or a torn discoid meniscus and is most commonly identified in
the medial tibiofemoral joint compartment.
This diagnostic pitfall should be considered
in the presence of an unusually large meniscus or meniscus fragments or a discoid medial meniscus [20].
The oblique meniscomeniscal ligament,
which extends from the anterior horn of one
meniscus to the posterior horn of the other meniscus with a reported incidence of
14%, can mimic a bucket-handle tear [21]
(Figs. 3A and 3B). Potential misdiagnosis of
an oblique meniscomeniscal ligament for a
bucket-handle meniscal tear may be avoided
by following the ligament with confirmation
of its classic anatomic orientation on consecutive images. Another mimic of a buckethandle tear is a rare congenital variant, most
commonly involving the lateral meniscus, referred to as a ring meniscus. A ring meniscus variant is characterized by a ring shape
in which the anterior and posterior horns are
connected by an inner horn bridge and presents on imaging as a complete ring of meniscal tissue [22, 23]. The lack of meniscal tissue loss in the anatomic location of the horns
and body of a ring meniscus and the welldefined smooth morphology and triangular
shape of the central inner horn component
should prompt this diagnosis [7] (Fig. 3C).
A meniscal flounce is an incidental redundancy or fold along the free edge of the meniscus (Fig. 3D). A meniscal flounce is commonly observed within the medial meniscus,
with an incidence of 0.25% on knee MRI

examinations [24, 25]. As opposed to morphologic changes of a meniscal tear, a meniscal flounce reflects a transient physiologic
distortion of the meniscal inner margin, typically seen when the knee is in a flexed position and typically disappears on full extension of the joint [25]. Occasionally, meniscal
tears can produce a flouncelike morphology,
but these typically show other indicators of a
meniscal tear [24].
MRI artifacts leading to pitfalls in meniscal assessment include truncation [26] and
motion artifacts [27]. Truncation or Gibbs
artifact may be seen as a series of low- and
high-signal-intensity linear artifacts running parallel and adjacent to interfaces of
abrupt signal intensity change. Such artifacts can be superimposed on the meniscus
as linear areas of high signal intensity simulating the MRI appearance of a meniscal
tear. However, such artifacts are manifested by subtle signal intensity changes exactly
paralleling the articular surface of the meniscus and on careful inspection can extend
beyond the boundaries of the meniscus itself. Magic angle effect can also lead to artifactual increased meniscal signal intensity
on short-TE MRI acquisitions of the knee,
particularly affecting the posterior horn of
the menisci as they extend to their posterior root attachments. Magic angle phenomenon is seen within highly ordered collagen
fibers, which are oriented at 55 relative to
the main magnetic field on MRI, and can be
seen clinically on MRI of obliquely oriented
portions of the menisci where meniscal collagen fibers are oriented at 55 to the main
magnetic field. It can potentially mimic signal intensity changes of meniscal degeneration on short-TE imaging acquisitions [28].
Increased signal intensity can be seen in
the absence of meniscal tears within the meniscus in a variety of settings. Intrasubstance
mucoid degeneration of the meniscus is identified as linear or globular increased signal
intensity within the meniscus and is often
asymptomatic [29, 30]. In the context of trauma, meniscal contusions can also produce a
similar appearance with an area of increased
intrameniscal signal intensity change that
is typically less discrete than either meniscal tears or intrameniscal degeneration and
is usually associated with adjacent marrow
contusion [31]. In children, it is also common to see peripheral high signal intensity within the meniscus, which reduces with
age and is thought to represent normal pe-
AJR:203, September 2014 517
Mohankumar et al.
ripheral meniscal vascularity [32]. Any of
these causes of intrameniscal signal intensity change can contact the meniscal articular surface, mimicking a meniscal tear. Increased specificity for a meniscal tear can be
achieved by identifying morphologic changes of the meniscus or visualization of intrameniscal high signal intensity extending to
the articular surface of the meniscus on at
least two contiguous slices. A positive predictive value of 9496% has been reported
in diagnosis of meniscal tear by using this
two-slice-touch rule [33].
In certain situations, the accuracy of MRI
assessment of meniscal tears may be diminished. The positive predictive value of MRI
for detection of longitudinal tears is significantly lower than other tear morphologies [16].
Tears located at the periphery, particularly at
the meniscocapsular junction, and those that
exit only the superior articular surface lead to
false-positive diagnoses. Interval spontaneous
healing of these meniscal tears is thought to
result in the lower positive predictive value for
longitudinal tears. In the presence of an ACL
tear, it has also been shown that the sensitivity for meniscal tears, particularly peripheral
tears of the posterior horn of the lateral meniscus, is also significantly lower. These tears
may be subtle and require careful diagnostic
scrutiny at MRI evaluation [34].
Displacement of meniscal tissue is an indirect sign of a meniscal tear and can present
with symptoms of joint locking and clicking.
A bucket-handle tear is a classic displaced
meniscal tear, and MRI has high accuracy
for detection of such lesions. More commonly, displaced meniscal fragments are identified adjacent to the posterior root of the medial meniscus, posterior to the PCL, or in
the medial and lateral gutters of the articulation [35]. Less commonly, unstable meniscal
tear fragments or flap tears may flip under
the meniscus itself. Identification and localization of flipped fragments are important as
the fragments may be situated in potential
blind spots on arthroscopy (Fig. 4).
Meniscal ossicles, most commonly seen
within the posterior horn of the medial meniscus, can rarely be mistaken for an intraarticular body [36]. The signal intensity that
is characteristic of the ossicle typically parallels that of marrow fat. Continuity of the
ossicle with the adjacent meniscus aids in
distinguishing a meniscal ossicle from an intraarticular body.
Although MRI offers excellent evaluation of the native meniscus, evaluation of a
518
postsurgical meniscus is more challenging.

Morphologic truncation of the meniscus and
persistent surfacing signal intensity on shortTE pulse sequences, reflecting conventional
criteria for diagnosis of preoperative meniscal tears, have limited accuracy of 5068%
in the diagnosis of a postoperative meniscal
tear [37, 38]. The presence of increased intrameniscal signal intensity contacting the
articular surface on short-TE sequences after meniscal surgery can represent a healing
tear, area of intrameniscal degeneration contacting the neoarticular surface after partial
meniscectomy, or the residual stable component of a treated meniscal tear. Changes
in meniscal morphology are also not specific for recurrent tearing and can reflect
changes after meniscectomy. Conventional
MRI, MRI arthrography, and CT arthrography have been advocated for evaluation of
the postoperative meniscus [37, 3942]. Reinjury of the meniscus can be most reliably
diagnosed by visualizing intrameniscal imbibition of intraarticular gadolinium on T1weighted images at MR arthrography or fluid
on T2-weighted nonarthrographic imaging
or by visualizing displaced meniscal fragments or meniscal fragmentation [43] (Fig.
5). Interval change in morphology of the meniscus in comparison with previous postoperative MRI, if available, is also indicative of
a recurrent tear.
Cruciate Ligaments
A variety of primary and secondary MRI
signs have been described in assessment of
complete tears of the ACL. Primary signs include discontinuity of the ACL, nonvisualization of the ACL, and replacement of the
ACL with an ill-defined masslike area consisting of hemorrhage. These signs have
high diagnostic accuracy in the evaluation of
complete ACL disruption [44, 45].
Potential pitfalls in assessment of ACL injuries may arise by reliance solely on sagittal
imaging in evaluation of the ACL. Prescribed
sagittal imaging planes may not adequately
parallel the ACL, and depending on the imaging plane orientation, slice thickness, and
interslice gap used at imaging, volume averaging may be encountered between the proximal ACL and the lateral femoral condyle.
This may result in erroneous observations of
intrasubstance signal intensity changes and
possibly incomplete visualization on sagittal imaging alone of contiguous fibers along
the entire course of the ACL. Such pitfalls
can be avoided by evaluating possible signal
intensity changes and ligamentous continuity on axial and coronal planes in addition to
sagittal MRI acquisitions of the knee [46].
A complete ACL tear may undergo scarring, and various scar patterns have been
recognized [47]. These include scarring of
torn ACL fibers to the PCL, roof of the intercondylar notch, or lateral femoral condyle.
In such scenarios, although the knee may remain clinically unstable, the MRI appearance of a scarred ACL can be erroneously
mistaken for a contiguous intact or partially torn ACL (Fig. 6). Scar formation at the
site of a chronic complete ACL tear can lead
to focal thickening, attenuated scar tissue, or
focal angulation of the ligament. However,
these features may also be identified to some
degree in normal ligaments or with ACL
partial tears [48]. Scarring onto a nonanatomic point within the intercondylar notch
or presence of prior imaging showing a complete tear are useful indicators of the severity
of the original injury.
MRI evaluation of partial tears of the
ACL is challenging [49], with relatively low
diagnostic accuracy [5052]. Partial tears
may be mistaken for complete tears, mucoid
degeneration, and normal ACL [50]. A partial tear of the ACL may show either focal
or diffuse increased intrasubstance signal
intensity as well as laxity or posteroinferior
bowing of ligamentous fibers. Partial tears of
the femoral origin of the ACL can be particularly difficult to diagnose on sagittal images. Similarly, isolated injuries of one bundle
may be overlooked when the other bundle remains intact. Interrogation of axial images
may be valuable in evaluation of the normal
low-signal-intensity ACL at its femoral origin as well as in assessing the degree of ligament fiber disruption in the setting of partial
ACL injuries [45].
Imaging the postoperative reconstructed ACL is a common indication for MRI.
Complete review of the surgical techniques
and imaging appearances of reconstruction grafts is beyond the scope of this article. During the first postoperative year,
biologic graft constructs undergo ligamentization and neovascularization resulting in
increased signal intensity of the graft on T1and T2-weighted sequences, which may be
mistaken for graft tear or graft impingement
[53]. Graft signal intensity changes during
the ligamentization process are not as high
as fluid on T2-weighted images, and the ACL
graft typically shows normal signal intensity by 1824 months [54, 55]. However, small

areas of persistent striated or globular signal intensity change may be evident within
ACL reconstruction grafts for several years,
even in the absence of symptoms [56]. These
findings may simulate graft changes associated with graft impingement or partial tears
but should be interpreted with caution in asymptomatic individuals with normal graft
positioning and a lack of graft discontinuity. Similarly, anterior translation of the tibia,
which has high specificity for tearing of the
native ACL [57], may be seen in the absence
of anterior translational knee laxity and has
low sensitivity and positive predictive value
for anterior knee laxity postoperatively [58].
In comparison with ACL tears, MRI assessment of PCL tears can be more challenging. In addition to focal ligamentous discontinuity, PCL tearing may be manifest simply
by ligamentous thickening, which may be
overlooked, especially if a relevant clinical
history is not provided [59]. Distinguishing
partial PCL tears from complete tears can be
especially challenging, and there may be a
discrepancy between clinical and MRI grading of PCL injuries (Fig. 7). Both partial and
complete tears can result in thickening of the
ligament with ill-defined margins and increased signal intensity [60]. Complete PCL
tears tend to show focal discontinuity more
commonly than partial tears and are more
frequently associated with other ligamentous
or meniscal injuries of the joint.
Chronic PCL tears have a propensity to heal and scar and can be easily overlooked on MRI [61]. In a study of 46 cases
of PCL tears evaluated at a mean interval of
15 months after injury, 28% showed an almost normal ligament with an additional
44% showing continuity of the ligament with
variable deformity on MRI [62]. Such chronic PCL tears may heal in a stretched state, resulting in lengthening of the ligament, which
may be difficult to assess on MRI despite
clinical features of PCL insufficiency. The
ratio of the lateral femoral condyle to PCL
length has been used as a method to diagnose
ligament lengthening in chronic tears, with a
mean ratio of 1.96 in normal individuals and
a decrease in the ratio in patients with chronic PCL tears [63].
Similar to the ACL, the PCL can undergo mucoid degeneration [64]. Distinguishing
mucoid degeneration of the PCL from a PCL
tear can prove a diagnostic challenge because
thickening and increased signal intensity of
the PCL can also be seen with longitudinal
interstitial tears. The tram-track appearance
of the PCL, manifested as homogeneous longitudinal increased intrasubstance signal intensity of the PCL bounded by well-defined
intact rims of low signal intensity, has been
described as a reliable MRI finding in mechanically stable PCLs with mucoid degeneration [65].
Collateral Ligaments
The medial collateral ligament (MCL) is
commonly injured in valgus injuries to the
knee. Acute MCL injuries are invariably associated with periligamentous edema. However, fluid and edema superficial to the MCL
is nonspecific and can be seen with medial
meniscal tears as well as medial compartmental osteoarthritis [66, 67]. These changes may mimic MRI findings of a partial lowgrade tear of the MCL. More significant
edematous changes may also be seen surrounding the medial restraints of the knee in
the setting of subchondral insufficiency fractures (Fig. 8). The intense edema, both osseous and soft-tissue that may be related to
repetitive stress on the injured subchondral
plate [68]; identification of subchondral linear signal intensity changes with intense edema; and commonly associated posterior root
tears lead to the correct diagnosis and differentiation from MCL injuries.
The posterolateral corner of the knee is
composed of a complex set of structures.
These include the fibular collateral ligament, popliteus tendon, popliteofibular ligament, arcuate ligament, fabellofibular ligament, and biceps tendon. Injuries to these
structures are typically associated with cruciate ligament injuries or multiligamentous
injuries. Although the fibular collateral ligament, popliteus tendon, and biceps femoris
are consistently seen on MRI, identification
of other structures is more variable [69]. Of
the more inconsistently visualized ligamentous structures contributing to posterolateral
corner stability, exclusion of injury and disruption of the popliteofibular ligament is the
most critically important for patient management. Isolated injuries of the popliteofibular
ligament, however, are rare, and MRI identification of injuries to the fibular collateral ligament and popliteus should raise concern for
concomitant popliteofibular ligament tears
and posterolateral corner instability [70]
(Fig. 9). Similarly, although the arcuate ligament is typically not well seen on MRI, posttraumatic edema and hemorrhage along the
posterolateral capsule and popliteal hiatus
may be features reflective of an arcuate liga-
ment injury. In individuals with posterolateral

corner instability and multiligamentous injury, the neurovascular structures should also
be scrutinized because they can be injured in
approximately 15% of cases [71].
Extensor Mechanism
A bipartite patella in which secondary or
accessory ossification centers of the patella
fail to unite with the main osseous body of
the patella is a normal developmental variant
seen in 2% of the population. The most common type is a bipartite fragment involving
the superolateral pole of the patella (75%).
A bipartite patella can be distinguished on
MRI from a fracture by the location of the bipartite segment, presence of well-corticated
margins to the accessory segment, and typical integrity of underlying articular cartilage of the patella overlying the incompletely
united accessory ossification center. Marrow
edema at the interface of the bipartite segment is suggestive of micromotion at the synchondrosis, and defects in the normally intact
articular cartilage may be features associated with symptomatic anterior knee pain [72]
(Fig. 10A). The dorsal defect of the patella is
a further variant thought to be related to normal enchondral ossification involving the superolateral patella, which is seen in up to 1%
of individuals [73]. On MRI, a dorsal defect
of the patella appears as a small symmetrically round subchondral bony defect with intact overlying articular cartilage within the
superolateral patella in contrast with osteochondritis dissecans of the patella, which is
more commonly central or superomedial in
location and often variable in shape and morphology [74] (Fig. 10B).
Magic angle effect in the patellar tendon is
common because of the orientation of highly
ordered collagen fibers of the tendon. Such artifacts can result in areas of increased signal
intensity on short-TE pulse sequences, particularly along the deep margin of the tendon,
with decreasing prominence on T2-weighted
acquisitions [75]. This is in contrast to signal
intensity changes seen in the setting of patellar tendinopathy, which are observed on both
short-TE and T2-weighted acquisitions.
Transient lateral patellar dislocation can
be a difficult diagnosis clinically, and patients are often referred for imaging for suspected meniscal or MCL injuries [76]. The
MRI diagnosis of transient lateral patellar
dislocation is classically characterized by
contusive injury to the medial facet of the
patella and the anterior aspect of the lateral
Mohankumar et al.
femoral condyle. Identification of osteochondral lesions and the integrity of the medial
patellofemoral ligament are critical factors
to accurately assess on MRI and important
features in clinical management of patients
with confirmed transient lateral patellar dislocations (Fig. 11). Patients with injuries to
the femoral attachment of the medial patellofemoral ligament are more likely to have
recurrent chronic instability and may be appropriate candidates for medial patellofemoral ligament repair or reconstruction [77].
Differentiation of MRI findings of traumatic
disruption of the medial patellofemoral ligament versus nonvisualization due to anatomic variation is characterized by findings of
edema and hemorrhage at the expected femoral origin of the medial patellofemoral ligament and along the medial-inferior border of
the vastus medialis obliquus as well as elevation of the femoral attachment of the vastus
medialis obliquus.
Signal intensity changes are commonly
encountered in relation to the fat pads anteriorly at the knee joint. Edema may be seen involving the superolateral aspect of the Hoffa
fat pad in the setting of patellar tendon lateral femoral condyle friction syndrome or in
relation to the quadriceps-suprapatellar fat
(Fig. 12). These changes can be associated
with symptoms of anterior knee pain and patellar maltracking. Additional findings of patella alta, lateral subluxation of the patella,
and swelling of the suprapatellar fat pad can
also be encountered.
Articular Cartilage
The excellent spatial resolution, tissue contrast, and multiplanar capability make MRI an
excellent tool for assessment of articular cartilage [78]. MRI of articular cartilage is susceptible to MR artifacts, including magic angle,
partial volume averaging, chemical shift, and
susceptibility artifacts. The collagen fibers
in articular cartilage are highly organized.
This can lead to magic angle effect resulting in focal increased signal intensity within the articular cartilage [79, 80]. Increasing
the TE will reduce this effect. At bone-cartilage interfaces, on nonfat-suppressed imaging, chemical shift artifacts related to the
marrow fat may be encountered, leading to
misregistration artifacts in the frequency encoding direction superimposed over areas of
articular cartilage, mimicking the appearance
of focal chondral lesions. Such artifacts can
be reduced by increasing the bandwidth, anatomically directing artifacts elsewhere in the
520
image by swapping the frequency and phase

encoding directions, or they can be eliminated by application of fat suppression [81]. Pulsation artifacts from the popliteal artery as
well as patient motion artifacts can also lead
to focal areas of linear or rounded signal intensity change that may mimic focal areas of
chondrosis or flap tears. Pulsation artifacts are
seen in the phase encoding direction and are
typically identified by a repeating pattern of
pulsation extending beyond the margins of the
articular cartilage. Truncation artifacts may
also be encountered in imaging of the articular cartilage, leading to a laminar appearance
within the articular cartilage [82, 83].
MRI is useful in assessment of osteochondral abnormalities within the knee. A particular imaging pitfall of note is femoral condylar ossification irregularities that can mimic
osteochondritis dissecans in the pediatric
population. These are particularly common
in the posterior aspect of the lateral femoral condyle and likely reflect a developmental variant related to the enchondral ossification of secondary ossification centers [84].
The posterior location, presence of intact
overlying normal articular cartilage, lack of
associated marrow edema, and presence of
multiple ossification centers are helpful in
distinguishing these developmental variants
from osteochondral lesions [85] (Fig. 13).
Bone and Soft Tissues
Hematopoietic marrow or red marrow
conversion can be a prominent finding in the
knee and can raise concern for a neoplastic marrow infiltrative process. Red marrow
conversion may be seen in a variety of settings, including anemia, smoking, and high
athletic activity [86]. On MRI, involved areas of hematopoietic marrow conversion
show intermediate-to-high signal intensity
on fluid-sensitive sequences and low-to-intermediate signal intensity on T1-weighted imaging. Typically, there is metaphyseal involvement, and several patterns have
been identified, including uniform confluent areas, punctate areas of signal intensity
change, and focal masslike areas of marrow
signal intensity change [87]. On T1-weighted
images, areas of red marrow are typically of
higher signal intensity than adjacent muscles
[88]. Sparing of the epiphyseal regions of the
distal femur and proximal tibia is a useful
identifier of red marrow (Fig. 14). On in- and
out-of-phase imaging, signal intensity dropout can be seen on out-of-phase images in the
setting of red marrow [89].
A cortical desmoid, or distal femoral cortical irregularity, is seen at the posterior aspect
of medial supracondylar femur in adolescents,
which is thought to be a tug lesion involving the adductor magnus insertion or medial
gastrocnemius head origin. The location and
knowledge of imaging appearance are important to distinguish a cortical desmoid from
other abnormalities, such as fibrous cortical
defect or parosteal osteosarcoma [90].
Synovial plicae are embryologic remnants of synovial membrane of the knee.
Three synovial plicae are commonly encountered at arthroscopy and imaging: the
suprapatellar, infrapatellar, and medial plicae, with a lateral plica less common. These
are most commonly asymptomatic but can
occasionally result in symptoms. The infrapatellar plica, anterior to the ACL and
extending through the Hoffa fat pad, may be
thickened and mistaken for focal synovitis
or part of the ACL. Medial plica syndrome
occurs in adolescents because of thickening
and inflammation of the medial plica [91].
A thickened medial plica extending into the
patellofemoral joint, with associated chondral changes of the patella or medial femoral condyle, in the absence of other causes
of symptoms, suggests a diagnosis of plica
syndrome [92] (Fig. 15).
Osseous and subchondral marrow edema
can often provide valuable insights to the
mechanism of traumatic injury sustained in
the knee, such as the edema pattern in pivot-shift injury, transient patellar dislocation,
and hyperextension injury.
Surrounding soft tissues can also reveal
anatomic variants. Muscle variants can easily be overlooked. These include accessory
heads of gastrocnemius muscle and an accessory popliteus or a double configuration to
biceps femoris [9396]. These can be associated with popliteal artery entrapment, a palpable mass, or common peroneal nerve compression, respectively.
Finally, vascular variants, such as popliteal artery entrapment, cystic adventitial disease, or deep vein thrombosis, may cause
symptoms around the knee and can potentially be overlooked on MRI of the knee unless specifically reviewed (Fig. 16).
Summary
In this article, we have reviewed the common pitfalls that are encountered in MRI of
the knee, knowledge of which is useful for
providing an accurate diagnosis when evaluating the images.
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Fig. 1Wrisberg rip and pseudotear.

AC, 26-year-old man with Wrisberg rip of posterior
horn of lateral meniscus. Sagittal fat-suppressed T2weighted MR image (A) (TR/TE, 3450/65) centrally
shows contusive injury consistent with pivot shift
injury. There is fluid cleft between meniscofemoral
ligament of Wrisberg (arrow) and posterior horn
of lateral meniscus (arrowhead). Sagittal fatsuppressed T2-weighted MR image (B) (TR/TE,
3450/65) through midlateral compartment shows
further lateral extension of fluid cleft (arrowhead)
consistent with tear. Coronal intermediate-weighted
MR image (C) (TR/TE, 3420/38) shows location of
sagittal slices (lines) in A and B.
D and E, 33-year-old man with Wrisberg pseudotear
of posterior horn of lateral meniscus. Sagittal
fat-suppressed T2-weighted MR image (D) (TR/
TE, 4060/67) through medial aspect of lateral
compartment shows cleft between meniscofemoral
ligament of Wrisberg (arrow) and posterior horn
of lateral meniscus (arrowhead). Sagittal fatsuppressed T2-weighted MR image (E) (TR/TE,
4060/67) through more lateral aspect of lateral
compartment does not show lateral extension of cleft
in keeping with normal interface.
Mohankumar et al.
Fig. 2Meniscocapsular tear and

meniscocapsular recess.
A, 30-year-old man with meniscocapsular tear.
Sagittal fat-suppressed T2-weighted MR image (TR/
TE, 3600/68) through medial compartment after acute
injury shows irregular vertical cleft extending all
way through meniscocapsular junction (arrowhead)
as well as periphery of medial meniscus. Adjacent
contusive injury to posterior medial tibial plateau is
also noted (asterisk).
B, 25-year-old woman with normal meniscocapsular
recess. Sagittal fat-suppressed T2-weighted
MR image (TR/TE, 3540/65) through medial
compartment shows smooth fluid-filled recesses at
meniscocapsular junction superiorly and inferiorly
(arrowheads) with central band at meniscocapsular
junction (arrow), which inhibits extension of fluid all
way superoinferiorly.
524
Fig. 3Meniscal variants.

A and B, 54-year-old man with oblique
meniscomeniscal ligament. Midsagittal fatsuppressed T2-weighted MR image (A) (TR/
TE, 3750/68) shows linear low-signal-intensity
structure (arrowhead) within intercondylar notch
mimicking displaced meniscal fragment. Axial fatsuppressed T2-weighted MR image (B) (TR/TE,
3660/65) through joint shows low-signal-intensity
structure (arrowheads) extending obliquely from
posterior horn of lateral meniscus to anterior
horn of medial meniscus, consistent with oblique
meniscomeniscal ligament.
(Fig. 3 continues on next page)

Fig. 3 (continued)Meniscal variants.
C, 23-year-old woman with ring meniscus. Coronal
intermediate-weighted MR image (TR/TE, 3300/36)
shows central triangular low-signal-intensity
structure mimicking bucket-handle tear (arrowhead).
Structure has smooth triangular appearance and
remainder of lateral meniscus was normal without
evidence of tear or loss of meniscal volume.
D, 28-year-old man with meniscal flounce. Sagittal
fat-suppressed T2-weighted MR image (TR/TE,
3350/72) through medial compartment shows focal
waviness to inner border of body of medial meniscus
(arrowhead) without signal intensity change or focal
clefts, consistent with incidental meniscal flounce.
Fig. 4Flipped meniscal fragments.

A and B, 48-year-old woman with multiple flipped meniscal fragments. Coronal intermediate-weighted MR image (A) (TR/TE, 3100/35) shows flipped meniscal fragment
(arrowhead) inferiorly into medial gutter deep to medial collateral ligament (arrow). Coronal intermediate-weighted MR image (B) (TR/TE, 3100/35) through posterior
aspect of joint shows further flipped meniscal fragment (arrow) superior to posterior root of medial meniscus.
C, 36-year-old woman with displaced meniscal fragment in posterior horn of lateral meniscus. Sagittal proton density MR image (TR/TE, 2150/15) through lateral
compartment shows bulky posterior horn with increased tissue inferior to posterior horn (arrowheads) as result of flipped meniscal fragment.
Mohankumar et al.
Fig. 5Postoperative menisci.

A, 32-year-old man with recurrent-residual meniscal tear. Coronal fat-suppressed T2-weighted MR image (TR/TE, 3800/70) 1 year after anterior cruciate ligament
reconstruction and partial meniscectomy of medial meniscus shows diminutive body of medial meniscus with vertical high-signal-intensity cleft through body
(arrowhead), consistent with recurrent or residual tear confirmed surgically.
B and C, 45-year-old man with prior partial meniscectomy and postsurgical changes without recurrent tear. Sagittal proton density MR image (B) (TR/TE, 2230/16) 3 years
after partial meniscectomy shows resection of part of inferior leaflet of horizontal cleavage tear with residual cleft visible on short TE image (arrowhead). Corresponding
sagittal fat-suppressed T2-weighted MR image (C) (TR/TE, 3750/70) does not show imbibition of fluid into cleft (arrowhead). No tear was identified at arthroscopy.
Fig. 625-year-old man with anterior cruciate ligament (ACL) rupture and recurrent scarring.
A, Sagittal fat-suppressed T2-weighted MR image of knee (TR/TE, 3400/66) shows complete discontinuity and rupture of midsubstance of ACL (arrowhead).
B, Sagittal fat-suppressed T2-weighted MR image of knee (TR/TE, 3500/68) obtained 3 years after initial injury shows low-signal-intensity fibers at site of prior rupture
(arrow). Proximal fibers are not well visualized because of partial volume averaging.
C, Axial fat-suppressed T2-weighted MR image of knee (TR/TE, 3600/66) through proximal ACL obtained 3 years after initial injury shows attachment of proximal ACL
(arrow) at lateral femoral condyle.
526
A
Fig. 728-year-old man with discrepancy between
clinical and MRI grading of posterior cruciate
ligament (PCL) tear. Sagittal proton density MR image
(TR/TE, 2140/19) of knee shows diffuse thickening
and increased signal intensity of PCL (arrowhead)
with intact fibers visualized. This was interpreted as
partial tear. Clinically, patient had grade III posterior
draw sign.
Fig. 862-year-old woman with subchondral insufficiency fracturing medial femoral condyle and secondary
medial collateral ligament (MCL) changes.
A, Sagittal proton density MR image (TR/TE, 2200/15) shows linear subchondral low-signal-intensity region
(arrowheads), in keeping with subchondral insufficiency fracture.
B, Axial fat-suppressed T2-weighted MR image of knee (TR/TE, 3450/58) shows thickening of MCL with
adjacent soft-tissue edema (arrow) mimicking MCL partial tear. Diffuse edema of medial femoral condyle is also
noted (asterisk).
Fig. 923-year-old man with anterior cruciate

ligament tear (not shown) and posterolateral
corner injury.
A, Coronal intermediate-weighted MR image (TR/
TE, 3150/32) shows focal edema involving styloid
process of fibula (arrow), consistent with undisplaced
arcuate fracture at attachment of popliteofibular
ligament (arrowhead).
B, Coronal intermediate-weighted MR image (TR/
TE, 3150/32) anterior to A shows associated tear of
fibular collateral ligament (arrow).
Mohankumar et al.
Fig. 10Patellar variants.

A, 41-year-old man with bipartite patella. Axial fatsuppressed T2-weighted MR image (TR/TE, 3500/70)
shows osseous fragment (arrowhead) involving
superolateral patella with low-signal-intensity
interface with patella. There is osseous edema on
both sides of interface. Overlying articular cartilage
is intact but shows focal signal change.
B, 31-year-old man with dorsal defect of patella.
Axial fat-suppressed T2-weighted MR image (TR/
TE, 3350/60) shows focal osseous defect (arrowhead)
involving lateral facet of patella. Overlying cartilage
is intact.
528
Fig. 11Patellar dislocation.

A, 23-year-old woman with acute transient patellar
dislocation. Sagittal fat-suppressed T2-weighted
MR image (TR/TE, 3530/65) through lateral
compartment shows extensive bone marrow edema
involving lateral femoral condyle (asterisk) and
large hemarthrosis. There is focal chondral defect
involving anterior aspect of lateral femoral condyle
(arrowheads).
B, 25-year-old man with acute transient patellar
dislocation. Axial fat-suppressed T2-weighted MR
image (TR/TE, 3600/70) shows bone marrow edema
of medial patella (asterisk) as well as lateral femoral
condyle. There is extensive edema and hemorrhage
along course of medial patellofemoral ligament with
nonvisualization of femoral attachment (arrow),
consistent with complete tear.
Fig. 12Fat pad edema.

A and B, 32-year-old woman with anterior knee pain. Sagittal fat-suppressed T2-weighted MR image (A) (TR/TE, 3500/60) shows increased signal intensity and swelling
of suprapatellar fat pad (arrowhead). Corresponding proton density image (B) (TR/TE, 2180/14) shows low signal intensity involving suprapatellar fat pad (arrowhead).
C, 41-year-old man with anterior knee pain. Sagittal fat-suppressed T2-weighted MR image (TR/TE, 3580/64) shows patella alta and focal area of edema involving
supralateral aspect of Hoffa fat pad (arrowhead).
A
Fig. 1310-year-old boy with distal femoral
ossification irregularity. Sagittal fat-suppressed
intermediate-weighted MR image (TR/TE, 3000/38)
through lateral compartment of knee shows area
of subchondral linear signal intensity change
involving posterior aspect of lateral femoral condyle
(arrowheads). There is no significant edema and
overlying articular cartilage is intact.
Fig. 1445-year-old woman with hematopoietic marrow involvement of distal femur.

A, Proton density image (TR/TE, 2300/15) shows heterogeneous marrow signal intensity changes involving
distal femoral diametaphysis (arrowheads). Signal intensity changes do not cross physeal scar, and there are
areas of interspersed fat within involved area. Patient had no other medical history. Addition of T1-weighted
imaging may be useful in atypical cases.
B, Axial fat-suppressed T2-weighted MR image (TR/TE, 3550/70) shows mild patchy hyperintensity of distal
femoral marrow (arrowheads).
Mohankumar et al.
A
Fig. 1528-year-old man with anterior knee pain
and clicking secondary to medial plica syndrome.
Axial fat-suppressed T2-weighted MR image (TR/TE,
3700/66) shows thickened medial plica (arrowhead)
extending into patellofemoral joint with adjacent
synovitis (asterisk). Focal chondral changes are
present involving medial facet of patella (arrow).
530
Fig. 16Incidental vascular findings.

A, 42-year-old woman with popliteal deep venous thrombosis. Sagittal fat-suppressed T2-weighted MR image
(TR/TE, 3200/70) in this patient who was referred for assessment of internal derangement of knee shows
heterogeneous signal intensity and expansion of popliteal vein (arrowheads) with surrounding soft-tissue
edema, consistent with deep venous thrombosis, which was confirmed by sonography.
B, 43-year-old man with cystic adventitial disease of popliteal artery. Sagittal fat-suppressed T2-weighted MR
image of knee (TR/TE, 3980/62) after acute knee injury shows incidental extensive cystic changes in relation to
popliteal artery (arrowheads).

Pitfalls and Pearls in MRI of The Knee

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Pitfalls and Pearls in MRI of The Knee

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M u s c u l o s k e l e t a l I m a g i n g R ev i ew

Rakesh Mohankumar 1,2

Pitfalls and Pearls in MRI of the Knee

Keywords: knee, ligaments, meniscus, MRI,

Joint Department of Medical Imaging, University Health

AJR 2014; 203:516530

he knee is the articulation most

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Pitfalls and Pearls in MRI of the Knee

with an incidence of 0.25% on knee MRI

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postsurgical meniscus is more challenging.

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Pitfalls and Pearls in MRI of the Knee

ment injury. In individuals with posterolateral

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image by swapping the frequency and phase

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Pitfalls and Pearls in MRI of the Knee

Fine JP. Clinical and MRI findings associated

sessed with 3.0 T MRI. Skeletal Radiol 2011;

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57. Vahey TN, Hunt JE, Shelbourne KD. Anterior

locations: where are the lesions? A prospective

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Pitfalls and Pearls in MRI of the Knee

C, Genant HK. Hematopoietic bone marrow in the

symptoms, and radiologic evaluation. RadioGraphics 2008; 28:481499

Fig. 1Wrisberg rip and pseudotear.

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Fig. 2Meniscocapsular tear and

Fig. 3Meniscal variants.

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Pitfalls and Pearls in MRI of the Knee

Fig. 4Flipped meniscal fragments.

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Fig. 5Postoperative menisci.

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Pitfalls and Pearls in MRI of the Knee

Fig. 923-year-old man with anterior cruciate

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Fig. 10Patellar variants.

Fig. 11Patellar dislocation.

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Pitfalls and Pearls in MRI of the Knee

Fig. 12Fat pad edema.

Fig. 1445-year-old woman with hematopoietic marrow involvement of distal femur.

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Fig. 16Incidental vascular findings.

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