Greece / Dr. Antonia Bintoudi

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?

Antonia Bintoudi: In Greece, MSK radiology is a new subspecialty within radiology and currently exists in few hospitals. Sports imaging is not included in basic radiology training but in everyday, routine patient scans where a trainee is able to gain early exposure. There are dedicated sports imaging courses organised either from the Hellenic Society of Musculoskeletal Radiology or from specific subcommittees of the European Society of Musculoskeletal Radiology in Greece.

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?

AB: Within the last 15 years, I have worked as an MSK radiologist in a large tertiary hospital located in northern Greece. It covers a large population area, with the main advantage of having two orthopaedic clinics specialising in athletic injuries. The hospital contains approximately 1,500 beds. The radiology department is equipped with one 3T MRI scanner, two CT scanners (one 16sclice and one 124slice), five ultrasound (US) scanners (Phillips EPIQ 7), fluoroscopy and three x-ray machines. I am the only MSK consultant at my department, therefore my everyday work schedule contains sports-related patient imaging, among other kinds. We report MSK MRIs, plain radiographs, US lists with MSK cases, MDT meeting for bone and soft tissue tumours, and interventional lists. MSK-related procedures (US, CT, fluoroscopy-guided procedures) are some of my everyday routine activities, which I thoroughly enjoy.

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?

AB: Different sports provoke different types of injuries. Therefore, muscle injuries are the most common type of injury as they affect a large patient population. Some of the major technical advancements over the past years have been US scan improvements with better image resolution, and easy portability. New therapeutic procedures accepted by WADA (World Anti-Doping Agency) such as platelet-rich plasma (PRP) injections are all helping to form accurate and fast diagnoses as well as direct treatment. Improvements in MRI scans and accessibility are a large benefit. Nerve injuries, labrum pathology and kinematics are considered some of the biggest challenges for an MSK consultant with a special interest in sports injuries.

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

AB: The most frequent sports injuries in our department are due to football and skiing. While football players can be injured during games and practice and often present with overuse injuries, skiing, on the other hand, causes high-speed trauma. Both are considered contact sports, providing by far the most robust data compared to limited-contact or non-contact sports. Lower extremities are the principal anatomic area for injuries in both sports. Nowadays, upper extremity injury rates are seeing significant increases during ski season. If there is a question regarding an avulsion/fracture, then plain radiographs are the first modality considered to evaluate patients. Ligament, tendon and muscle-related injuries are initially scanned with ultrasound. If complex injuries are suspected, then an MRI scan should be performed. Overuse injuries, labrum pathology and osteochondral defects can be evaluated by MR or CT arthrography (also performed in our department) to gain more information. Follow-up clinics are mostly required for pathologies, which are easily performed with ultrasound.

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

AB: Most traumatic injuries can be detected with imaging, mostly with US and MR scans. For example, after a massive knee injury during any sport, be it football, skiing, or volleyball, MR scans have a high spatial resolution capability to detail ligamentous, cartilage, meniscal, and of course bone contusion pathology. Furthermore, follow-up can be performed easily. Ligamentous and muscle injuries, and their follow-ups, can be evaluated with ultrasound, which is a cheaper and readily available alternative. Additionally, specific contact sports such as American football, which is not popular in Greece, are implicated with sports-related sudden death due to repetitive concussion. CT and MRI brain scans add vital information according to the existing brain pathology. Even plain radiography scans can provide valuable information. Early adolescence training, as in elite athletes, is known to provoke impaired growth, developmental or skeletal variations. Radiography scans can provide information on normal skeletal maturation or developmental anomalies due to extensive training such as with gymnast wrist.

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?

AB: Different roles exist within a team, and I consider the MSK radiologist to be the conductor between all other clinicians. Through different guided procedures, radiologists give vital information regarding diagnosis, extent of injury, indirect proposal of treatment, treatment prediction and even treatment. Referral physicians should be aware of the specific mechanism of injury and the limitation in consulting athletes. Orthopaedics and neurologists are obligated to explain the mechanism of injury or even presume a hypothetical diagnosis in detail. Cardiologists have a more pre-emptive role.

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

AB: Ultrasound scans include breakthroughs alongside new interventional techniques for treatment, such as PRP injections, giving radiologists new prospects regarding accurate, simple and cheaper follow-ups and treatments. This means that MSK radiology is involved throughout the patient’s care process from diagnosis to post-treatment care.

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?

AB: Most of the normal variants, congenital or anatomic differences noted within the human skeleton, can be found accidentally during sports imaging. Some of them, such as flat glenoid fossa, the cause of patellar mall tracking and impingement syndromes, are predisposition factors for injury during training. Knowledge of this in athletic patients leads to successful non-operative or even operative decision making. Some image findings can also elicit the durability and compatibility of certain athletes in a particular sport. This may be something used and developed more aggressively in the future.

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?

AB: I am not familiar with such procedures. As far as I know, there is no such centre in Greece, especially in Northern Greece where I live. However, I am aware that these centres exist in professional football; for example, the Manchester United football club. Though I may not be involved, knowledge on athlete injuries from these centres can help us understand how much the human skeleton is capable of enduring and what frames can deal better with certain activities.

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?

AB: I believe the need for imaging has increased rapidly over the years. This is also the case within MSK radiology. Depending on every case, specialised trauma physicians or sport-expert orthopaedics should accompany the team to make accurate diagnoses and request appropriate imaging. If not, the referral physicians should be aware of sport-related injury centres and refer the patient directly to a specialised orthopaedic for consultation.

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?

AB: Radiation exposure during imaging studies can be reduced using three different methods. First, exposure can be limited if the patient or team decide not to perform the required study at all. This would follow the qualified guidance of referral clinicians, as well as understanding and discussion of the impact of such decision on possible outcomes. Second, if imaging is vital then a non-ionising scanning method such as ultrasound or MR should be considered or even selected. Third, specific protocol scans with less radiation must be used to create images in MSK radiology. Referral GPs or trauma physicians can play a vital role in reducing radiation risk to athletes by considering these risks when making imaging referrals. However, the best solution is to always have MSK radiology involved as part of the team in these decisions.

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?

AB: Motor vehicle-related sports have the highest risk of causing brain injuries.

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

AB: This can depend on the age of the athlete. In my department, initial evaluation is often a non-contrast-enhanced CT scan which is used to exclude subarachnoid or intracranial haemorrhage and skull vault fracture. It is easier, cheaper and highly accessible. If results are negative and clinical issues persist then an MRI scan might be performed.

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

AB: The mechanism of an injury generally correlates with specific injury patterns. Follow-up findings correlate with the time of injury, which also gives further information. Even complications after intracranial haemorrhaging, if there are any, can lead to new conclusions.

We have learnt over the years that protection gear has a significant impact on injuries. Having good headgear in high speed related sports with facial cover has a higher protective benefit than simple headgear with no facial screen.

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

AB: Within my institute, brain imaging is reported by our neuro-radiology colleagues, who also look into similar patterns when it comes to injury and sport-related injuries. Having new high-tesla MRI scanners and specific sequences and protocols helps radiologists identify the pathology of interest better than ever. A significant reduction in communication error and higher yield to diagnosis are a result of having the correct trauma pathways so that a patient is seen by the correct team, the appropriate investigation is requested, and the correct radiologist is reporting the scan. Making these pathways uniform means that throughout Europe, we have a systematic approach to managing these patients as well as the ability to collect data, audits and research so that we can further develop this field.