India / Dr. Ankur Shah

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?

Ankur Shah: In India, as in most countries, we do not have a special focus on sports imaging during radiology training. There are few special courses dedicated to sports imaging for interested radiologists. At most places, radiologists who practice musculoskeletal radiology do the sports imaging.

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?

AS: I work in a private diagnostic centre where we receive patients referred for magnetic resonance imaging (MRI) and computed tomography (CT) studies from Ahmedabad and adjoining cities. Sports-related imaging comprises only a part of my regular work schedule.

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?

AS: In our part of the world, the number of people who play cricket significantly outnumbers all other sports. Therefore, we get a maximum number of references for imaging of cricket-related injuries. However, for the past few years, we have been increasingly receiving players with injuries caused by football and badminton practise. Subtle stress injuries of bones provide the greatest challenge to radiologists in diagnosis.

ESR: Please give a detailed overview of the sports injuries with which you are most familiar and their respective modalities.

AS: Sports-related injuries comprise a large spectrum of conditions including various soft tissue and osseous injuries of various grades. Many injuries commonly occur while playing active sports; many other injuries occur during training period. Some injuries are acute while others occur over a period of time and manifest at a certain point of time. Stress injuries of various bones are most commonly encountered in our practice. As a lot of our patients with sports-related injuries are cricketers; many are fast bowlers with stress injuries of lower lumbar vertebrae. The act of fast bowling gives significant load on lower lumbar vertebrae, and many of them have either acute or acute-on-chronic injuries of pars interarticularis or pedicles of lower lumbar vertebrae (L3, L4 or L5 vertebrae). Most of them are diagnosed with the help of MRI of the lumbar region. MRI is the modality of choice for detection of subtle stress injuries. MRI usually shows bone marrow oedematous changes on water sensitive sequences due to trabecular injuries involving pars interarticularis or pedicles. Radiographs and even CT scans are usually normal in acute setting and early injuries. In players having repeated injuries, bone sclerosis may develop in this region. And these are the cases where CT scans may give additional information as compared to MRI with better detection of sclerosis. Acute stress injuries, if not treated, can progress to fracture of pars interarticularis – spondylolysis or fracture of pedicle – pediculolysis. These are well detected with both MRI and CT. Stress injuries of other bones may also be seen. Another common location is the diaphysis of tibia. MRI helps in the detection of bone marrow oedematous changes in medullary cavity of tibial diaphysis extending to cortex and oedematous changes in adjacent soft tissue – muscles and subcutaneous tissue. There can be associated periosteal reaction at the site of stress injury that may be detected by CT or radiograph as well.

ESR: What diseases associated with sporting activity can be detected with imaging? Can you provide examples?

AS: Imaging can help detect chronic overuse injuries as well as acute injuries. It may also help identify underlying nutritional disorders. As discussed earlier, cricket players very commonly have chronic injuries of lower lumbar vertebrae with sclerosis of pars interarticularis and pedicles. Chronic injuries at the origin of hamstring muscles are also fairly common, and many of them have avulsion injuries of ischial tuberosity – the site of origin of hamstring muscles, which can be detected, with the help of MRI and CT. Imaging is extremely helpful in the detection of acute injuries of muscles, tendons, ligaments and supporting structures. As bowling and throwing result in injuries of rotator cuff tendons and labrum, they can be detected with the help of MRI. MR arthrography can help in better detecting and characterising injuries of glenoid labrum. At times, imaging also helps in the detection of underlying nutritional abnormalities. When a sports player presents with multiple or repeated stress injuries or stress injuries at an unusual site, the possibility of underlying calcium or vitamin D deficiency is suspected, and biochemical investigations are carried out to confirm the deficiency.

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?

AS: In present sports medicine practice, imaging and radiologists play a very important role. As clinical diagnosis based on symptoms and physical tests is not always accurate, imaging is extremely important to assess the exact site and severity of injury. The relationship between the radiologist, surgeon and sports physician is always interdependent. No one alone can take care of sports-related injuries without cooperation from each other. Clinical inputs and observations from the radiologist help to understand the injury and decide further management.

ESR: The role of the radiologist in determining diagnoses with sports imaging is obvious; how much involvement is there regarding treatment and follow-up?

AS: With the increasing number of intervention procedures carried out for pain relief and early return of the player to active sports, the role of the radiologist in treatment is increasing day by day. The severity of the injury determines further treatment plan, and the decision to whether to treat the injury conservatively or surgically is taken by the surgeon, based on discussion with the radiologist. For follow-up, the radiologist also plays an important role by guiding the healing process based on imaging findings. The imaging appearance of the injury on follow-up determines further rehabilitation plans.

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?

AS: Radiology can help detect the injuries early on, many times even before symptoms appear, and allows treatment of the condition with the rest or supportive measures to prevent further damage. Subtle marrow oedema in pars interarticularis or pedicle of vertebrae, if treated with proper rest, can prevent spondylolysis/pediculolysis and possible spondylolisthesis. Detection of an annular fissure in intervertebral disc can prevent disc prolapse by altering the load on the vertebrae and proper rehabilitation to strengthen the supportive muscles. New research projects are going on with ultrahigh field MR magnets of 7T to detect T2 relaxation values of annulus fibrosus of intervertebral discs to predict weakening and loss of strength of collagen fibres of annulus that can lead to higher chances of disc prolapse in the future. This knowledge will be helpful in changing the physical activities and rehabilitation methods to prevent problems related to disc prolapse in the future. At present, information provided by medical imaging is very limited to help enhance the performance of athletes.

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?

AS: The demand for imaging has definitely been increasing in sports medicine over the last few years. Proper clinical evaluation by a sports medicine specialist can help in narrowing down the list of differential diagnoses and reduce the number of imaging investigations for sports-related injuries. Many times, using ultrasound, a relatively affordable modality, instead of MRI for patient follow-up can help reduce imaging expense.

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?

AS: As MRI and ultrasound cover a major part of sports-related injuries imaging, and both modalities do not use ionising radiation, the risk of developing diseases related to frequent exposure to radiation is very low in athletes. The radiation dose in x-ray examinations performed in long bones is very low. CT scan does give significant exposure to radiation. However, use of proper imaging protocols can help to reduce radiation exposure in these examinations. Use of lead shields for thyroid and gonads also helps reduce the risk of radiation exposure to sensitive organs. Judicious use of imaging modality and switching to a modality without radiation exposure can help limit the negative impacts of radiation in athletes.

European Society of Radiology: Sports imaging also applies to sports-related injuries of the brain. In case you are familiar with this, please also answer the following questions:

ESR: Which sports have the highest risk of inducing brain injuries?

AS: In our country, sports like boxing, where chances of brain injury are very high, are less prevalent. Kabaddi players do suffer from brain injuries due to frequent falls at times.

ESR: What imaging modalities do you use with traumatic brain injury specifically in athletes?

AS: For athletes, we prefer a brain MRI for brain injuries unless when bony injury of skull vault or facial bones is suspected. In those cases, CT scan is preferred. MRI allows detection of subtle non-haemorrhagic contusions and surface contusions adjacent to the skull vault with very high sensitivity.

ESR: What can be learned from sports-related injuries that can be applied to a broader use, for example those sustained through automobile or other accidents that cause traumatic brain injury?

AS: Sports-related brain injuries are often subtle and difficult to detect unless proper MR sequences are obtained in proper imaging plane(s). This can help us detect subtle injuries in patients having traumatic brain injuries caused in other settings than sports practise.

ESR: How have advances in brain imaging allowed you to predict patient outcomes more accurately?

AS: With advances in brain imaging and newer MRI sequences like susceptibility-weighted imaging (SWI), it has become possible to detect very subtle areas of contusions or intraventricular haemorrhage that can help explain patient symptoms and clinical condition, and also help predict patient outcome.