European Society of Radiology: Sports imaging is the main theme of IDoR 2019. In most countries, this is not a specialty in itself, but a focus within musculoskeletal radiology. In your country, is there a special focus on sports imaging within radiology training or special courses for interested radiologists?
Andrey Uchevatkin: In Russia, unfortunately, there is no such specialty as ‘sports radiology’. At the same time, the need for such a focus in the field of musculoskeletal radiology is clear due to the rapid development of professional and non-professional sports, as well as sports medicine. Unfortunately, most residency programmes in radiology do not include either individual courses in sports radiology or separate advanced courses in musculoskeletal radiology. Due to the short period of residency in radiology (two years), residents only have time to study classical radiography out of all the possible techniques for musculoskeletal system examinations. Typically, there is no time during the residency to learn about MRI, CT and ultrasound of the musculoskeletal system. This is the main reason young specialists need to receive comprehensive training in musculoskeletal radiology soon after their residency. There are a lot of great opportunities nowadays for young radiologists in Russia who are interested in musculoskeletal radiology. In Moscow, at the Scientific and Practical Centre of Medical Radiology, which is headed by Professor Sergey Morozov, we organise two-day seminars on the sports injuries of one of the large joints. There have been numerous courses on sports injuries of the knee, hip, ankle, shoulder, elbow and wrist joints where many radiologists have been trained. The course usually consists of lectures and a detailed analysis of clinical cases which may include up to 50 cases for each joint, including MRI and CT. The course begins with a detailed analysis of the anatomy and the role of various imaging modalities in the field of MSK (musculoskeletal). Then we proceed to the lectures and cases that are devoted to a specific pathology; for example, knee ligament tears, rotator cuff pathology, ankle impingement, etc. On the second day of the course, a traumatologist who specialises in sports injuries and arthroscopic surgery of one of the joints joins our team of teachers. A surgeon talks about the main methods of clinical diagnosis and treatment of sports injuries, including the most common arthroscopic manipulations. He is also involved in the discussion on MRI, CT and x-ray images, sharing his point of view and explaining to young radiologists which information makes our reports relevant for the clinician. This part of the course is usually the most interesting for the students (especially when the teacher/radiologist and teacher/surgeon are about to fight each other). For those radiologists who do not have the opportunity to come to Moscow, there is an online training option which includes many webinars recorded at the Scientific and Practical Centre of Medical Radiology and an online learning system, created for sports radiology.
The Russian Society of Radiologists (RSR), headed by Professor Valentin Sinitsyn, through international relations (including the ESSR), organises joint sessions on musculoskeletal radiology at international congresses.
International courses on MSK radiology are periodically held in Russia, such as the ESMRMB course in St. Petersburg in 2017 (Advanced MR Imaging of the Musculoskeletal System), organised by professors Alla Karpenko and Prudencia Tyrrel.
ESR: Please describe your regular working environment (hospital, private practice). Does sports-related imaging take up all, most, or only part of your regular work schedule?
AU: I have been working in a private clinic for several years and have worked as a radiologist, head of the out-patient department, CEO and lecturer (including seminars in musculoskeletal radiology). Despite the large number of activities and business trips, I manage to work with patients daily, many of whom with sports injuries and other musculoskeletal pathologies. Thanks to my almost daily work with patients (my ‘favourite’ modality is MRI), communication with traumatologists and orthopaedists, participation in international congresses, as well as constant teaching, I manage to stay at the forefront of medical knowledge in musculoskeletal radiology.
ESR: Based on your experience, which sports produce the most injuries that require medical imaging? Have you seen any changes in this regard during your career? What areas/types of injuries provide the greatest challenge to radiologists?
AU: Based on personal experience, I can say that the greatest number of injured patients who need radiology examination are football and ice hockey players. Of course, participation in any sport is potentially traumatic and in daily practice there are completely different injuries that require radiological diagnosis. In the process of working as a radiologist, it seems to me that the number of injured non-professional athletes has greatly increased in recent years, which is probably due to the growing trend of living an athletic lifestyle while at the same time lacking a serious approach to any sport and training process, which is necessary (this is true not only for injuries, but also for diseases of the cardiovascular system). Moreover, in my practice, I more often see so-called ‘sport-specific’ injuries in non-professional athletes or ‘weekend warriors’. Based on my own experience, including consulting work, I can say that the most problematic areas for the diagnosis of sports injuries are the joints of the hand and shoulder. Examination of these joints often requires direct arthrography, which significantly increases the sensitivity and specificity of MRI and CT. I consider chronic injuries and postoperative examinations (for all modalities) to be the most difficult to diagnose in sports radiology as they have the greatest number of errors and misinterpretations associated with them.
ESR: Please give a detailed overview of the sports injuries with which you are most familiar and their respective modalities.
AU: My favourite topic in sports radiology is the MRI of sports injuries of the lower limb, which includes joint trauma as well as muscle and tendon tears. With this opportunity, I would like to focus on the latter. Muscles that only have a proximal, belly and distal tendon are quite common and are found throughout the body. However, there are other shapes that muscles can take. The different types of muscle architecture allow muscles to contract in different ways. Depending on the structure, there are muscles which are prone to injuries. It is well known that muscles are more prone to injury if they cross two joints (because these muscles carry a lot of load), have multiple heads, have a high proportion of type II fibres and have multiple musculotendinous junctions. Type II muscle fibres are also called fast fibres because they are characterised by high force/power/speed production, but are more prone to fatigue. Depending on the type of sport, some athletes are more likely to get pelvic and thigh-tendon and muscle injuries. This is especially true for young athletes involved in American football, hockey, football, basketball and speed running. For example, 35% of football injuries are muscle injuries of which 37% are related to the hamstring, 17% to the quadriceps and 30% to groin muscles. Although the injury can occur anywhere within the muscle, the most common sites depend on the patient’s age. Among children and adolescents – apophysis avulsions (fractures of the hip and pelvis) are very common. In the pelvic area there is ischial tuberosity, iliac crest and the inferior or superior of the anterior iliac spine. Among adults we usually have myotendinous injuries or tears at the tendon and muscle insertion sites. Elderly patients tend to have tears of degenerated tendons.
I would like to focus on the few very important moments which should be kept in mind when describing MRI. For clinicians, it is very important to estimate the athlete’s rehabilitation time, which depends not only on the severity of MRI features but also on the trauma mechanism (direct and indirect injuries). In the first case we will use the term ‘muscle contusion’ whereas in the second case we will use different terms like muscle tear with (or without) tendon involvement, so that the clinician is able to estimate the rehabilitation time properly. What we should also remember is that in most cases with MRI, it is impossible to differentiate muscle contusion and indirect injury without knowing the patient’s history. Therefore, you should speak with patients and sports physicians before making a report.
It is very important to know whether we have a patient with their first muscle injury or a patient with a muscle re-injury as 16% of muscle injuries in elite football and American football are re-injuries. Muscle re-injuries are associated with a 30% longer absence from competition than the original injury. Therefore, it is critical to perform correct evaluation and diagnosis of muscle re-injuries.
There are three grade classifications of muscles injuries which are well known. I think all radiologists use them in practice. There are a couple of interpretations of this grading system we can find in literature but, the problem is that we have a wide range and interpretation of grade 2 injuries. There are a lot more comprehensive classifications which were proposed in Munich. These classifications include direct and indirect types of muscle injuries and divide indirect injuries into functional and structural, which is very important to know. When we only find oedema in muscle, it does not mean we have fibre disruption. In most cases, it simply means that we have a functional muscle injury which includes delayed-onset muscle soreness, spine related neuromuscular muscle disorder and muscle-related neuromuscular muscle disorder. This is important to keep in mind as treatment and rehabilitation of these conditions are different from those we use with structural muscle injuries.
A lot of thigh muscles originate from pelvic bones and it is important to precisely evaluate the pelvic area in athletes with clinical symptoms. The most common pathological sites in the pelvic area are: hamstring tendons (including ischial tuberosity avulsion), ischiofemoral impingement, piriformis muscle, rectus femoris (including subspine impingement, AIIS avulsion and apophysitis), sartorius tendon and of course athletic pubalgia (athletic hernia).
Concerning differential diagnosis, it is necessary to remember stress fractures of the pelvis, which are easily visible on MRI and can cause pain in the pelvic area. Usually on MRI we find severe oedema on fluid-sensitive pulse sequences and sometimes a hypointense line on all sequences.
The most common modalities we use for muscle and tendon injuries of the lower limb are ultrasound and MRI (I prefer MRI frankly, because with ultrasound it is often hard to find minor muscle injuries as well as evaluate pelvic tendons). Of course, the x-ray and CT are very useful in evaluating bone injuries as well as ossifications and myositis ossificans.
ESR: What diseases associated with sporting activity can be detected with imaging? Can you provide examples?
AU: Many diseases can be associated with sport, especially when it comes to professional sport, when, in addition to heavy and constant physical activity, athletes need to travel a lot. In addition to acute and chronic injuries of any areas, these are pathologies of the respiratory system (asthma, infections), gastrointestinal tract (viral infections), mental diseases and sleep disorders associated with chronic stress and jet lag as well as diseases of the cardiovascular system. One of the most common pathological conditions found in athletes, and often requiring imaging, is overload changes of different localisation, mainly involving the bones and bone-tendon junctions. The spectrum of pathologies includes bone marrow oedema, stress fractures, chronic tears of the apophyses in children and adolescents, tendinosis and partial tears of the tendons with ossification formation in a chronic injury. In my practice there have been several instances of young athletes coming for a follow-up after an extended period with overload bone marrow oedema, with or without a subcortical stress fracture. After more detailed visualisation, it turned out that osteoid osteoma was the cause of the pain. All sports radiologists should keep even such rare cases in mind.
ESR: Radiologists are part of a team; for sports imaging this likely consists of surgeons, orthopaedists, cardiologists and/or neurologists. How would you define the role of the radiologist within this team and how would you describe the cooperation between radiologists, surgeons, and other physicians?
AU: I completely agree that a radiologist can successfully work and develop into a team with other clinicians (this is true for any subspecialty of radiology). Moreover, I am sure that the success of patient treatment depends on successful communication between the radiologist and the clinician. When the radiologist understands what information they must provide to the clinician in each specific situation, and the clinician in turn knows what to expect from a particular modality (and from the particular radiologist, of course!), the correct diagnosis is not delayed and the treatment is done in a timely and competent manner. This is especially important when it comes to a chronic injury or postoperative patients and, before writing a report, the radiologist must understand the clinical context or know the type of the surgery that was performed. To develop and maintain high-level communication, we often invite surgeons to our radiological conferences and seminars, and they invite us to their congresses. There are radiology sessions at many traumatological congresses that take place in Moscow where we tell surgeons and sports doctors about the possibilities of different modalities in musculoskeletal radiology. The interest of surgeons in our specialty is huge and there is usually not enough seating room in the hall at such sessions!
ESR: The role of the radiologist in determining diagnoses with sports imaging is obvious; how much involvement is there regarding treatment and follow-up?
AU: In my opinion, the role of the radiologist in treatment evaluation and sports injury patient follow-up is great, but it should also not be too exaggerated. The need for imaging during treatment of sports injuries is very much dependent on the clinical situation. If the clinical situation is understandable and the effect of the treatment or rehabilitation in line with the expectations of the clinician, then in most cases, expensive follow-up imaging is not required. Moreover, it is necessary to remember that even with successful treatment, dissociation may occur between clinical symptoms and images that can mislead the clinician. For example, it is well known that bone marrow oedema can persist for a long time on MR images, even in the absence of any clinical symptoms. If the effect of treatment is not obvious or any complications take place, then it is often necessary to get additional images before the clinician decides to change tactics. The only exception to this rule is a postoperative patient. After surgery, we always need to get the images we will be able to rely on in the future should any complications occur.
ESR: Radiology is effective in identifying and treating sports-related injuries and diseases, but can it also be used to prevent them? Can the information provided by medical imaging be used to enhance the performance of athletes?
AU: Yes, there are many examples. First, radiology allows a sports doctor to decide whether a patient can participate in professional sports at all (starting with the cardiovascular system) without incurring serious health consequences. Secondly, with imaging (for example, visualisation of overload changes of various anatomical structures) a sports doctor can correct the training process for a specific athlete as well as change the rehabilitation tactics. Also, we should remember that radiology is constantly developing and now we can evaluate not only anatomical and structural changes, but also the function and metabolism of muscles in athletes using MRI (DTI, spectroscopy, BOLD imaging, ASL perfusion, T2 mapping) and PET, as well as assess joint cartilage (MRI cartilage mapping).
ESR: Many elite sports centres use cutting-edge medical imaging equipment and attract talented radiologists to operate it. Are you involved with such centres? How can the knowledge acquired in this setting be used to benefit all patients?
AU: In the Moscow Scientific and Practical Centre of Medical Radiology there is a consulting department, where any radiologist working in a city public clinic (using a server from the Moscow healthcare department) can send a complex study including any images of the professional athlete, and receive consultation. I work in this department as a consultant in musculoskeletal radiology and help my colleagues who do not regularly see such patients, to deal with difficult cases. The presence of a server with images from all Moscow public clinics allows you to quickly adjust the MRI scan protocols that are used in various radiology departments, adjusting them to ESSR standards. Together, this improves the quality of diagnosis, increases the level of trust between surgeons, sports doctors and radiologists, and, of course, helps to treat the patients in a timely and competent manner.
ESR: The demand for imaging studies has been rising steadily over the past decades, placing strain on healthcare budgets. Has the demand also increased in sports medicine? What can be done to better justify imaging requests and make the most of available resources?
AU: Of course, the need for imaging is constantly growing in any field of medicine and sports medicine is not an exception. In my opinion, there are two main reasons for the growing need for imaging in sports medicine: first, the growing popularity of sports among non-professional athletes and the constant development of top-level professional sports, leading to an increase in the number of various injuries; second, radiology is developing in parallel with sports traumatology, including surgical minimally invasive treatment. For example, 10–15 years ago, for the treatment of an ankle injury it was enough for a traumatologist to understand whether there was a fracture or not. With the modern development of arthroscopic methods for treating instability and other pathological conditions of the ankle joint, a traumatologist not only needs an x-ray examination, but also MRI, which increases the cost of diagnosis. However, the increase in cost (and, of course, quality) of the initial examination of the patient should help reduce the total cost of treatment. It is clear that it is better to immediately perform an expensive examination, quickly make the correct diagnosis and prescribe adequate treatment than to save on the initial diagnosis, bring the patient to the chronic stage of the disease and, as a result, spend much more on his treatment, rehabilitation and subsequent socialisation. Tighter cooperation is necessary when optimising the total cost of patient care and the use of expensive, but also more informative diagnostic methods. This should be done between radiologists and clinicians, medical professional communities and insurance companies. It is also critical to actively implement international guidelines and improve medical education.
ESR: Athletes are more prone to injuries that require medical imaging. How much greater is their risk of developing diseases related to frequent exposure to radiation and what can be done to limit the negative impacts from overexposure?
AU: Honestly, I do not think it is a very big problem for sports trauma imaging. First of all, athletes hardly ever require ‘heavy’ CT examinations such as multiple injuries patients. On the other hand, routine examinations with modern x-ray and CT equipment allow for very high quality images with low radiation exposure. Major venders have been working very hard over the past years to this end. Also, we know that we often only need MRI or ultrasound for sport injuries, because among them are a lot of soft tissue, cartilage and occult bone pathologies.
ESR: Do you actively practise sports yourself and if yes, does this help you in your daily work as MSK radiologist?
AU: I would say my daily work as MSK radiologist ‘helps’ me to not actively practise sport! I am joking of course, but seeing so many images of sport trauma prevents me a little bit from active sport practise. Sometimes I go jogging which helps me in my daily work, allowing me to tune my bandwidth (I am sorry, but MRI is the best modality ever) for receiving mostly ‘good stress’.
Dr. Andrey Uchevatkiny is radiologist and CEO of the CELT clinic in Moscow, a lecturer and radiologist (musculoskeletal system) at the Scientific and Practical Centre of Medical Radiology, Moscow, and ESR, ESSR and Russian Society of Radiology member. His main research interest is MRI of the musculoskeletal system. Dr. Uchevatkin has authored or co-authored 17 peer-reviewed publications. He is a permanent lecturer at national and international meetings (including ECR 2015, 2017, 2018, ESSR 2017) and speaker at the ESMRMB School on Advanced MRI of the Musculoskeletal System in 2017.