ESSR Sports Sub-Committe MRI Imaging Protocols

The publication of these MRI protocols is supported by the Football Association

With acknowledgement to the Department of Musculoskeletal Radiology, Chapel Allerton Hospital, Leeds, UK. for their origination of the protocols presented here.

List of Available Protocols (click on link)

Back Protocols

Routine Lumbar Spine for low back pain and sciatica

Chapel Allerton Side-Strain Protocol

Upper Limb

Lower Limb

Muscle Tear

Other Spine and Body

Back Protocols

Routine Lumbar Spine Protocol for low back pain and sciatica

Coverage should be from T11 down to S2, with sufficient slices to include left and right nerve roots (see Fig. 1/2)

Protocols

Sag T2 (FS) to include tips of transverse processes
Sag T1 to include tips of transverse processes
Axial T2 lower 3 disc levels (plus any other stenosed level) – L3/4 to L5/S1 parallel to each disc. (As in Fig.3)
Axial T1 lower 3 disc levels (plus any other stenosed level) – L3/4 to L5/S1 parallel to each disc. As above.
Coronal oblique T2FS and T1– centred on L5/S1 parallel to sacrum/SIJ (As in Fig.4)

Note: If coccygeal pain mentioned on request (coccydinia), do STIR sag coccyx.

Chapel Allerton Side-Strain Protocol

This technique is entirely dependent upon the availability of a small Field of View surface coil (see below). If your unit does not possess one, complete the recommended sequences, using either the spine coil or a larger surface coil – if possible, the patient should be positioned to lie on the affected side (this minimizes motion artefact from breathing).

Patient Positioning (Critically Important)

Ascertain the exact position of the suspected tear and mark this with an oil capsule. Position the coil over the capsule and secure in place with tape and/or bandages. Position the patient supine and plug the coil in. Check that the capsule/coil haven‟t moved from original position.

Protocols

Large Field of View localiser
Large Field of View FISP‟s (oil capsule finder) in all 3 planes
Large Field of View STIR Coronal of whole abdo (include oil capsule) – provides the Radiologist with an accurate (Rib) level of where the tear is.
Small FoV (80x80mm) T2FS Axial centred on oil capsule (in Fig.5a & 5b)
Small FoV T1 Axial (as above)
Small FoV (80x80mm) T2FS Coronal Oblique (as in Fig.6)
Small FoV T1 Coronal Oblique (as above)
Check with Radiologist/Clinician

If using a larger surface coil, use high res (3mm’s, 160x160mm FoV) STIR sequences in place of the small FoV T2 Fat Sat’s and T1’s.

Upper Limb Protocols

Shoulder Protocol

Positions:

1) Standard

Supine, hand by side, palm up. If palm up not possible, then thumb up. Must not be internally rotated.

2) ABER

Hand palm up behind head, or at least above head

Scan Planes:

1) Axial

Do first, needed for setting up coronal oblique
Aligned perpendicular to the plane of the glenoid
Must include acromion on most superior slice
Must cover whole of glenoid (see green Field of View on fig.7 below)

2) Coronal Oblique

Set up from high axial slice that shows supraspinatus tendon (SST – red arrow on fig.8 below)
Align along SST (green line on Fig.8 below)
Slices must cover from coracoid process anteriorly and include entire humeral head

3) Sagittal Oblique

Perpendicular to coronal oblique plane
Must extend laterally to include whole humeral head and extend medially to include whole of coracoid process

ABER Protocol

Align from coronal scout perpendicular to glenohumeral joint line (perpendicular to glenoid)
Ideally this will be along the humeral shaft but if arm is very abducted the angle of section will be less than this (see Fig.9)

Shoulder Coil Protocols

1) Routine Protocol

Axial PD TSE (fat sat)
Coronal Obl PD TSE (fat sat)
Coronal Obl T2 TSE (fat sat)
Sagittal Obl T1 SE
Sagittal Obl T2 TSE (fat sat)

2) MR Arthrogram Protocol

Axial T1 SE
Axial T1 SE (fat sat)
Sagittal Obl T1 SE (fat sat)
Coronal Obl T1 SE (fat sat)
Coronal Obl T2 TSE (fat sat)

3) Body Matrix Coil (Reposition patient)

ABER Position T1 SE Axial Oblique (fat sat)

Elbow Protocol

Position

“Super-man” position with elbow placed inside knee coil (or Flex Coil if elbow locked in flexed position)
If above not achievable – supine with arm by side (using flex or body matrix coil). Watch out for phase-wrap, and ONLY select Flex coil when scanning.

Scan Planes

1) Axial

Must do first as needed to set up coronal and sagittal plane
Position from superiorly, 1cm above humeral epicondyles; and inferiorly, 2cm below the radial head.

2) Coronal

Plane here is critical. Set up along anterior aspect of distal humerus (see Fig. 10 below). This gives a plane of section through the two epicondyles.

3) Sagittal Oblique

Perpendicular to coronal oblique plane (see Fig.10 below)

Protocols

1) Routine Protocol

Axial PD TSE
Axial T2 TSE (fat sat)
Coronal PD TSE
Coronal Obl T2 TSE (fat sat)
Sagittal Obl PD TSE (fat sat)

2) MR Arthrogram Protocol

Axial T1 SE
Sagittal T1 SE (fat sat)
Coronal T1 SE (fat sat)
Coronal T2 TSE (fat sat)

Wrist Protocol

Position

Arm must be supinated. This can be achieved using dedicated quadrature or surface coil either in horizontal position with palm up, or in vertical position with thumb up.
Wrist in neutral position, no radial or ulnar deviation and no flexion or extension.

Scan Planes

1) Axial

Must do first as needed to set up coronal and sagittal plane – to include from radial/ulnar styloid processes to above carpo-metacarpal joints.

2) Coronal

Plane here is critical. Line coronal plane up along anterior (volar) aspect of distal radius (Fig.11). It is essential to use an axial slice from a level 2cm below the distal radio-ulnar joint.

3) Sagittal

Perpendicular to coronal plane – to include all soft-tissues either side of radius/ulna.

Protocols

1) Routine Protocol

Axial PD FSE
Coronal T1 TSE
Coronal T2 TSE (fat sat)
Sagittal T2 TSE (fat sat)
+ 3D acquired in Coronal Plane - VIBE

2) MR Arthrogram Protocol

Axial T1 SE
Sagittal T1 SE (fat sat)
Coronal T1 SE (fat sat)
Coronal T2 TSE (fat sat)
Coronal 3D VIBE

3) Suspected Scaphoid Fracture

Sagittal T2 TSE (fat sat)
Coronal T1 SE
Coronal T2 TSE (fat sat)

4) Scaphoid Non-Union

Axial PD TSE
Coronal T1 TSE
Coronal Obl T2 TSE (fat sat) angled through scaphoid – see Fig.12
Sagittal Obl T2 TSE (fat sat) – see fig.13
Coronal post Gadolinium T1 TSE (fat sat)

Lower Limb Protocols

Knee Protocol (without knee coil)

Scan Planes

1) Axial

Established parallel to the knee joint line. Include whole patella, down to fibula head (see fig.14 below)

2) Coronal

Set up (on axial slice) along posterior aspects of the femoral condyles on the axial plane (see green line on diagram below).
Coverage to include posterior aspect of patella to 2cm behind femoral condyles.

3) Sagittal Oblique

Set up on an axial slice - along medial aspect of lateral condyle. This is approximately along the line of the ACL (see Fig.15).
Coverage must include both colateral ligaments.

Knee Protocol with Knee Coil/Foot Coil/Body Matrix (Size dependent)

1) Routine Protocol

Axial PD FSE (fat sat)
Coronal PD FSE (fat sat)
Sagittal Obl PD FSE (fat sat)
Coronal T1 SE
Sagittal Obl T2 FSE (fat sat)

2) Patellar tracking (beach ball)

For Patellar tracking studies (beach ball test) the patient is positioned prone with their ankles over the inflated beach ball. An oil capsule is placed on the back of the affected knee. When ready the stopper is removed from the beach ball and the patient asked to deflate it by pressing down onto the table. Ensure the patient does not lift their knees off the table during the deflation and that they use a constant pressure.

Routine knee sequences
Re-position patient prone (as described previously).
Axial localiser.
Sag Localiser over both knees.
GRE dynamic sequence over two minutes (Dynamic TFL)...temporal resolution of around 7 secs. Need at least 1 sagittal and 3 axial through the patella at each time point. As the leg is extended against the deflating beach ball the patella moves superiorly so on set up most distal slice should be at or around the mid patella. Include both knees with sagittal on symptomatic side. If both symptomatic please state which side the sagittal has been acquired from. Place oil capsule on symptomatic side.

Ankle and Foot Protocols

Scan Planes given relative to tibial shaft!

Figure shows expected coverage of sagittal FOV with the expected coverage of the coronal (Fig.16) and Axial (Fig.17) series superimposed.

Ankle and Hindfoot

1) Routine Protocol (In this order)

Axial PD FSE
Axial T2 FSE (fat sat)
Sagittal T2 FSE (fat sat)
Coronal PD FSE
Coronal T2 FSE (fat sat)

2) Impingement Protocol

Routine protocol as above
Axial and Sagittal T1 Post Gad (fat sat)

Forefoot

SCAN PLANES GIVEN AS SAGITTAL, LONG AXIS (GREEN LINE) AND SHORT AXIS (RED LINE) Fig.18

Routine Protocol

FISP‟s in all 3 planes
Long axis T2 TSE (fat sat) or STIR
Short axis PD TSE
Short axis T2 TSE (fat sat) or STIR
Sagittal T1 SE

Muscle Tear Protocols

Suspected Muscle Tear Protocol

1) Routine Protocol

Check with patient re: site of suspected tear and mark with oil capsule(s) if appropriate.

Axial and Long Axis FISP‟s (to localise)
STIR/T2FS Coronal/Ssgittal
STIR/T2FS Axial
T1 Coronal
T1 Axial
Gad may be prescribed in some cases (check with radiologist)

2) Post exercise protocol

Routine protocol as above
10 – 15 minutes moderate exercise
T1/STIR Axial immediately after cessation of exercise.
Radiologist may advocate post exercise, post contrast imaging.

Other Spine and Body Protocols

Routine Sacro-Iliac Joints

Centre at lower costal margin (as per L-spine).
STIR thoraco-lumbar spine (S1/2 up to T8/9).
FISP axials through SI joints.
T1 coronal oblique through SI joints (angled to sacrum, as seen in Fig.19A/B)
T2 FS coronal oblique (as above).

Routine Cervical Spine

Coverage should be from (superiorly) pituitary gland, down to T3/4, with sufficient slices to include left and right nerve roots.

Protocol

Sag T2
Sag T1
Axial T2 “Medic” (T2* Gradient Echo) C3/4 to C7/T1
Include sag STIR if any high signal in the cord.

Routine Thoracic Spine

Always place an oil capsule (red arrow) in the mid-line at T12/L1 prior to commencing the examination. Coverage should be from C7/T1 down, to include the entire conus medularis (as seen below in Fig.22/23)

Protocol

Large Field of View Sag FISP (oil-capsule finder)
Sag T2 (must include oil capsule at bottom of FoV)
Sag T1

IF ABNORMALITY (review)

Axial T1 of abnormal areas
Axial T2 of abnormal areas

Whole Spine

This examination is split into 2 separate fields – C/T-spine and L-spine. Begin at the section that is most relevant, and move to the next. Overlap of fields is essential.

Routine L spine

Sag T2 of C and T spine (from pituitary down to conus or overlap)
Sag T1 of C and T spine (from pituitary down to conus or overlap) IF ABNORMALITY (review)
Axial T1 and T2 of abnormality (may be “disc” axials or “blocks”)

Post-Op Spine Routine protocol

Sagittal T1FS + Gad (if metal-work present, omit FS)
Axial T1FS + Gad (As above)

Brachial Plexus

Sag T1 from cervical spine to midpoint of arm
Sag T2FS from cervical spine to midpoint of arm
Cor T2FS - FOV to include both shoulders
Ax T2FS from level of C5 to inferior axilla
Coronal SPACE of exiting nerve roots
Gadolinium not routinely given – discuss with radiologist as appropriate

Pelvis and Groin

Oblique axial plane here is critical for the adductor muscle insertions – see Fig.25

Coronal STIR of pelvis (anterior abdominal wall, back to posterior sacrum)
Sag FISP, to include entire pubic ramii (for the sole purpose of planning the axial obliques).
Axial T2FS pelvis (L5/S1 to lesser trochanters)
Oblique axial reduced FOV (parallel to superior pubic ramus) T2FS (see diagram)
Oblique axial reduced FOV (parallel to superior pubic ramus) T1FS + Gadolinium

Hip Pain

Cor T1 both hips
Cor T2FS or STIR both hips

If normal perform:

Axial T2FS pelvis (L5/S1 to below lesser trochanters) and stop.

If abnormal perform:

Axial T1 abnormal side (if both do pelvis)
Axial T2FS abnormal side (if both do pelvis)
Sag PD symptomatic hip joint

MR Arthrogram Hip

Axial T1FS of injected hip (red lines on Fig.26)
Coronal T1FS of injected hip (blue lines on Fig.27)
Sagittal T1FS of injected hip (yellow lines on Fig.27)
Coronal T2FS of injected hip
Axial oblique T1 WITHOUT FS (parallel to femoral neck on coronal scans – green lines on Fig.26)

HAMSTRINGS - ACUTE INJURY

ROUTINE PROTOCOL

Check with patient re: site of suspected tear and mark with oil capsule(s) if appropriate.
Area of interest will be posterior, so spinal coil elements alone are satisfactory. If suspected site of tear is medial/lateral or unsure, add Body Matrix/Large surface coil anteriorly and wrap over ?site of tear for extra signal. Hamstrings insert proximally into the ischial tuberosity and distally into the proximal portions of the tibia/fibulaComplete the following sequences (in order):

Axial and Long Axis localisers (find oil capsule)
STIR/T2FS Coronal (Blue lines on Fig’s) - to include tear site + 1 muscle insertion (closest)
STIR/T2 FS Sagittal (Red lines on Fig’s) - to cover tear site + 1 muscle insertion (closest)
STIR/T2 FS Axial (Green lines on Fig’s) - cover just the tear (if appropriate) or oil capsule (if no tear seen)
T1 Sagittal (copied exactly to STIR/T2FS Sagittal)
T1 Axial (copied exactly to STIR/T2FS Axial)

It is important to note that the desired coverage is entirely user-dependent - ie gauge this from the size of the tear/oedema present or the area of pain reported by the player. If no tear is seen, double-check edge of field of view because tears DO occur some distance from where the player indicates (referred pain). If T2FS was chosen for long axis imaging, be careful because loss of fat suppression is common at the far reaches of the FoV. Repeat sagittals with STIR if in any doubt.

HAMSTRINGS - RECURRENT/TROUBLESOME/NON-ACUTE INJURY

ROUTINE PROTOCOL

For players complaining of a long history of pain or recurrent injuries, it is important to image the entire hamstrings (from top to bottom) of the affected side. This situation will most commonly arise with proximal insertion pain (ischial tuberosity) - on Coronals try to include both sides for comparison.

Follow “Acute Injury” protocol
Add a STIR/T2FS & T1 sagittal to cover rest of hamstrings, and review.
Add axials if pathology present.

THIGH (QUADRICEPS) - ACUTE INJURY

ROUTINE PROTOCOL

Check with patient re: site of tear and mark with oil capsule(s) if appropriate. Area of interest will be anterior, so always use a surface coil/body matrix coil over this area for extra signal.

Axial and Long Axis localisers (find oil capsule)
STIR/T2FS Coronal - to include tear site + 1 muscle insertion (closest)
STIR/T2 FS Sagittal - to cover tear site + 1 muscle insertion (closest)
STIR/T2 FS Axial - cover just tear (if appropriate) or oil capsule (if no tear seen)
T1 Sagittal (copied exactly to STIR/T2FS Sagittal)
T1 Axial (copied exactly to STIR/T2FS Axial)

CALF - ACUTE INJURY

ROUTINE PROTOCOL

Check with patient re: site of tear and mark with oil capsule(s) if appropriate. The area of interest here will be posterior, therefore use of a spine coil is essential. Combine this with a surface coil or, preferably a peripheral angio coil for optimal image quality.

Axial and Long Axis localisers (find oil capsule)
STIR/T2FS Coronal (Red Lines on images) - to include tear site + 1 muscle insertion (closest)
STIR/T2 FS Sagittal (Blue Lines on images) - to cover tear site + 1 muscle insertion (closest)
STIR/T2 FS Axial (Green Lines on images) - cover just tear (if appropriate) or oil capsule (if no tear seen)
T1 Sagittal (copied exactly to STIR/T2FS Sagittal)
T1 Axial (copied exactly to STIR/T2FS Axial)

Ends