The Netherlands / Dr. Bas Maresch

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?

Bas Maresch: Radiology training in the Netherlands is a five-year programme under the supervision of the Dutch Radiologists Association (NVvR) completed in both an academic and non-academic, a teaching and non-teaching hospital in accordance with the national curriculum. The training consists of two phases; a common trunk phase of 2.5 years concerning general radiology, and a differentiation phase of 2.5 years with advanced training in one or two subspecialties such as musculoskeletal radiology. After this five-year training, a fellowship of one or two years, depending on the choice made during the differentiation phase, a further differentiation in a subspecialty can be made. A special focus on sports imaging is not available within this radiology or fellowship training. In all teaching hospitals, musculoskeletal radiology is part of the training, but only in a few centres is sports imaging or sports-centred healthcare a dedicated topic in the portfolio of the radiology department or hospital. No special courses on sports imaging in the Netherlands are organised under the supervision of the NVvR. Some enthusiastic Dutch sports radiologists organise courses specifically concerning sports imaging. The Dutch Association of Sports Medicine (VSG) organises specific courses on sports imaging regularly, intended mainly for sports physicians. The Dutch Olympic Committee*Dutch Sports Federation (NOC*NSF) organises, among other things, sports imaging masterclasses for their elite sports physicians. The development of new and more advanced technologies in ultrasound, CT, MRI and image-guided interventions has delivered a tremendous impact on the detection, treatment and understanding of sports pathology. In the last two decades, sports specific imaging courses in Europe and abroad have been developed as radiologists are playing a specific and more substantial role in the diagnosis and management of elite and non-elite athletes. In my academic training as a radiologist, 25 years ago, I started practising and training high-resolution ultrasound of the musculoskeletal system independently, together with my colleague Matthieu Rutten, during coffee breaks and after hours in clinical cooperation with orthopaedic surgeons. Earlier in my career, I was a member of the study group Dutch Musculoskeletal Ultrasound Society, where MSK ultrasound was developed, and teaching courses with hands-on training were organised. Since then, I have developed and expanded MSU and all other sports imaging modalities in my practice, together with dedicated sports radiologists Frans Timmer, Gert-Jan Spaargaren and Jacco Spermon, and in close collaboration with elite sports physician Peter Vergouwen and his colleagues, an elite sports medical network, the Dutch Olympic Committee NOC*NSF, TeamNL, national sports associations, national sport teams, and sports agencies.

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?

BM: Years ago, cooperation with elite physicians, athletes and the Dutch Olympic Committee was formalised with the foundation of the Radiological Centre Top Sport (RCT), focusing on diagnostic imaging and image-guided treatment for elite athletes. NOC*NSF facilitates expanded medical care for their Olympic and Paralympic ‘status’ and high-potential athletes.

Ever since the Olympic Games in Beijing, RCT has provided a second opinion facility during all Olympic and Paralympic Games for the Dutch delegation. Innovation from this has led to the possibility of reviewing diagnostics from all over the world, not only via a PACS system but also accessibility via a laptop, tablet or smartphone. In recent years, NOC*NSF started a concept of concentration and quality improvement in the Netherlands by creating five centres of Topsport and Education (so-called CTOs) where sports facilities, medical facilities and education are optimised. At these centres, talented and elite athletes and teams from different sports are able to train, study and live.

Our elite sports physicians take care of a wide variety of national and international athletes and teams. Together we are part of the large CTO Papendal. Accreditation by TeamNL as a High-Performance Partner (HPP-status) has been granted to our elite sports physicians, our sports pulmonologist and the Radiological Centre Topsport. Nutrition, physical activity and sports are the key focusses of Hospital Gelderse Vallei. The intensification of sports medical care during the last ten years culminated in the foundation of Sports Valley earlier this year. Sports Valley is a high-performance medical centre that provides diagnosis, treatment, support, screening and second opinions for elite and amateur athletes in an interdisciplinary setting with sports orthopaedic surgeons, sports physicians, sports radiologists, sports pulmonologists and a sports consultant from every other medical speciality. In addition, a medical network performs research on nutrition and sports in collaboration with Wageningen University, SportsInnovator, Eat2Move and the Nutrition & Healthcare Alliance.

Musculoskeletal and sports radiology form the majority of my work next to general radiology. At this moment it is with great pleasure that I am the chair of the RCT and Sports Valley, as well as the medical manager of a cluster of different specialties concerning sports and physical activity at my hospital.

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?

BM: In our practice, we see a lot of different types of athletes from various sports. Each sport has its own set of particular demands and injuries, so there are a large variety of peculiar stresses, injury patterns and types of injuries we encounter on a daily basis. Two broadly defined categories of sports-related injuries are acute traumatic and chronic overuse injuries, which are better understood due to the vast improvements in ultrasound, CT and MRI, CT/MRI-arthrography and functional and hybrid imaging techniques. Image-guided interventions, especially ultrasound and less numerous CT, are performed across the board. Their superior accuracy and efficacy compared to blind injection are recognised and increasingly requested by our referring physicians. The greatest challenge is not only to accurately depict and interpret the anatomical structures, variations and pathology, but also to put it into perspective and to understand the functional and sports consequences for the athlete, the treatment, incidental findings and the variety in incidence in athletes. Of course, we have to provide the referring clinician with the best information possible to help in the diagnosis, differential diagnosis, choice of treatment and information for surgery planning and techniques.

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

BM: Ultrasound of the MSK system and peripheral nerves has had our specific attention with its high resolution, availability, strong dynamic imaging capabilities, and low costs, since the beginning of its availability, and it is a highly consulted diagnostic tool in our department, constituting around fifty to seventy per cent of our total ultrasound practice. It is very understandable that nowadays it is at times referred to as ‘the new stethoscope’. It is not only widely used for diagnosis but also for follow-up in the healing process and for guided interventions and injections. MRI is, of course, the other key diagnostic tool for the evaluation of the soft and hard parts of the MSK system. Our Sports Valley and cooperating elite physicians are the national team doctors of different Dutch national sports associations; athletics, volleyball, ski, tennis, judo, hockey, BMX, cycling, table tennis, handball, sailing, water polo associations and multiple Paralympic associations such as paracycling, wheelchair basketball and winter sports. Next to these associations, elite athletes from a variety of sports, sports agencies and teams such as skating, golf, soccer, badminton, karate and baseball are regularly treated in our hospital. The expected sports pathology and injured tissues determine the choice of the imaging modality and sometimes more than one modality is needed. For the proper evaluation of sports injuries, knowledge and availability of the full range of imaging modalities is necessary and used to its full spectrum, helping us to explore the boundaries between what is normal and what is pathological.

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

BM: The majority of acute traumas and chronic overuse injuries are presented by adult athletes. Special care and attention to children and adolescents must be maintained as paediatric overuse injuries are becoming more prevalent with more children playing competitive sports more intensely and at a younger age. A few examples are the gymnast wrist, osteochondritis dissecans in the elbow and apophysiolysis. Although the general sports population is young, an underlying disease such as a malignancy always has to be taken into account, especially in an uncommon presentation of symptoms. Imaging plays a larger role in sports than just MSK imaging. Also, in cardiovascular imaging, ENT (ear, nose, and throat), lung diseases and other specialties have to be taken into account when working in a sports medicine clinic. The role of sports medicine and imaging is gradually expanding due to better understanding of the most prevalent diseases and associated risk factors and the role of sports in health prevention. The significant burden of lifestyle-related diseases and the economic impact in an ageing society needs to encompass it in preventive and peri-operative and therapeutic healthcare. Non-communicable diseases such as cardiovascular diseases, diabetes, stroke, obesity, cancer, and the global trend of decreasing physical activity benefit from attractive, low-cost strategies of health promotion and sustainability via sport and physical activity. Sarcopenia is more prevalent with advancing age and many diseases and is recognised as a risk factor for adverse health outcomes. Imaging analysis is investigated for its potential role.

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?

BM: Radiologists are nowadays positioned as an important player in sports medicine teams.

Evaluation of imaging techniques has made pathology and pathophysiology more clearly visible, reliable and more understandable; subtle findings are also more easily detectable. Also, subspecialisation, mono-and interdisciplinary science progress, and a more clinically orientated perspective have contributed greatly to the role of the radiologist. Close contact, constructive debate, and teamwork with sports physicians, orthopaedic and trauma surgeons, physiotherapists, cardiologists, neurologists, pulmonologists, as well with other specialities are key for best practice. But also, effective management, speed, an accurate diagnosis and the site of delivery are valuable commodities for elite and amateur athletes. Within Sports Valley the cooperation between the different specialists is very intense. This interdisciplinary approach ensures excellently integrated and optimum sports-medical care. It broadens our horizon, deepens our knowledge and combines the often interesting search for expected and sometimes unexpected diagnosis.

With our elite sports physicians, we have created a one-day policy for elite athletes. By working closely together as a multidisciplinary team, the phrase “we are waiting for the player to have a scan” has changed to “we are waiting for the player to be assessed by our medical team.” As a sports medical team, we can significantly improve the clinical management of sporting injuries and thus enhance the performance and health of all exercising individuals. It is often challenging, exciting and even a lot of fun to work as a sports radiologist, proving very rewarding when one can tell and show athletes that a cause and solution for their problem have been found. We have the same mindset as the elite athlete or patient, “the will to win”. Teamwork is the only way to go.

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

BM: Next to the confirmation of an accurate diagnosis, we need to help in management planning and return to play. We constantly spar to make the right diagnosis and determine the right treatment. When debating, we have to take into account the strengths and limitations of each imaging modality but also of the physical examination and different therapeutic options.

Elite athletes are individuals with a higher awareness and understanding of their body’s physical and physiological function and therefore often want to be more involved in the management of their injury. Involvement of the athlete, coach, physiotherapist and manager in injury management is important for them to understand the injury and its extent, including the choice for a specific treatment and prognosis as this improves compliance with treatment and prospects for the best outcome.

The role of the radiologist has evolved from just diagnostic imaging to image-guided interventions and prognostication of return to play (RTP). Image-guided treatments are widespread, especially ultrasound-guided injections with corticosteroids, local anaesthetics, PRP, Actovegin/Traumeel, hyaluronic acid and other injectables that enhance tissue healing and accelerate RTP. Other percutaneous image-guided treatments are percutaneous tenotomy, prolotherapy and high-volume injections. US-guided local anaesthetic injections during tournaments, match-day and next to the pitch seem to be increasingly performed in diagnosis and treatment. There is an increasing interest in improved grading of muscle injury and prediction of RTP. The obvious question is how long it takes until a player may return to their athletic activities. Several muscle injury and grading systems have been developed to categorise injuries; (modified) Peetrons, Chan classification, the British Athletics Muscle Injury Classification (BAMIC), Munich Consensus, and the Barcelona/Aspetar classification. At this moment, there is no strong evidence that MRI is useful in reliably predicting RTP. There is no routine follow-up imaging in muscle injuries. Follow-up can be used in, for instance, Peetrons grade 2 persisting clinics or in re-injury. Association of outcome with more sophisticated MRI classification systems with RTP (such as Munich, Barcelona) are a way forward together with studies and development of potential new MRI techniques such as T2 mapping, Diffusion Tensor Imaging, and MR elastography.

With the physician, it is also important to point out the (long term) risks of some acute or chronic injuries in an athlete’s career and the period after their active sporting career. The short-term desire to return to the pitch may outweigh concerns about long term health. The habitus of athletes sometimes needs to be considered in treatment and training. In, for example, volleyball, a more lax posture, or looseness of a joint or muscle, can be positive for sports performance but also carries the risk of developing certain types of injuries related to increased laxity.

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?

BM: In most pre-participation medical assessments, radiological investigations have limited to no role. In sports, cardiac screening and pre-signing medical assessments are more often performed, and imaging is more often incorporated. Defining a zero-base line status is performed when screening elite athletes. Previous images can help to differentiate and interpret the frequently encountered clinically insignificant findings in elite athletes. The IOC has developed a periodic health examination aimed at monitoring the health of athletes throughout their athletic career. While there is no specific imaging input, this may well be used to monitor ongoing pathology. Whether radiology can pre-empt injuries or disease is a highly discussed topic and the results of this discussion are not yet final. Instantaneous access to imaging can help to determine if an athlete can safely return to competition. There is often a time pressure in preparation for the next game, qualification or tournament. Imaging can help to decide if there is a significant injury due to which the athlete has to withdraw from a game or tournament or if the athlete will be able to continue to compete. This is particularly important in professional team sports during the formation of a team.

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?

BM: As part of the Centre of Topsport and Education Papendal, the Dutch Olympic Committee demands the highest quality in sports radiological imaging in an optimum organisation and environment for their elite athletes. As a member of the Radiological Centre Topsport and Sports Valley, we not only closely collaborate with our dedicated team of medical sports specialists in my hospital but also with a diversity of elite sports medical specialists all over the Netherlands. To enable improved access and improvement in quality and interdisciplinary teamwork, a Central Topsport Archive is at the verge of enrolling together with the other CTO centres in the Netherlands, establishing a national elite athletes PACS system. In addition, Sports Valley invests in scientific research to improve the medical care of athletes. Sports Valley is specifically intended for elite athletes and all amateur athletes. In this setting, all the knowledge acquired and delivered is available no matter what their sporting capabilities are. Moreover, in our Hospital Gelderse Vallei, food, vitality and preventive care are priority topics of interest and excellence with the intention of providing good medical care at the right place to the right person. Furthermore, cooperation with general practitioners in our local region has developed to provide better network medical care.

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?

BM: Just as in general increase in demand for imaging studies, this certainly also applies to sports-related imaging. In the Dutch healthcare system, there is a regulated framework. Optimisation is targeted by means of standardisation and guidelines, and by promoting an integrated approach to keep healthcare affordable. Radiology products are in many cases part of an integrated healthcare product. While dealing with financial constraints, efforts are made for every part of the healthcare product to be overall as effective as possible. In the Netherlands, limitations exist as imaging can only be requested by a referring physician. Centralisation promotes optimal use of expensive imaging equipment, including central archiving, and it allows for the important correlation with a patient’s ‘image history’. Studies have shown that higher ultrasound expertise leads to substitution of MRI for less expensive ultrasound, resulting in savings. However, experience is needed to be able to perform firm and reliable ultrasound imaging reports. Radiologists appear to have a ‘gatekeeper’ function as more imaging is performed in centres with self-referral for ultrasound. On the other hand, patient comfort of direct imaging, MSK expertise, improvement of profession and savings in hospital care are mentioned when performed by non-radiologists. Diagnostic imaging has over the last couple of years been increasingly performed outside radiology departments. There is much debate about the levels of competency of non-radiologists (including general practitioners, physiotherapists and sports physicians) using user sensitive imaging modalities such as ultrasound. Concerns are about education and training requirements, correlation and knowledge of the full spectrum of imaging modalities, interdisciplinary feedback and less central archiving of images and reports and its accessibility, and transparency. Next to quality arguments, financial arguments are in favour of teamwork in sports medicine.

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?

BM: In our institute (and presumably in the Netherlands), treated athletes are not overexposed to radiation as ultrasound and MRI make up the vast majority of performed imaging modalities of this group. The ALARA principle on radiation (as low as reasonably achievable) is also applied to athletes.

ESR: Do you actively practise sports yourself and if yes, does this help you in your daily work as MSK radiologist?

BM: Yes, I play tennis, field hockey and golf. I do like to think that this helps me in my work as a sports radiologist, allowing me to understand the drive of an athlete and feel comfortable in a sporting environment. With advancing age, I have become more prone to injuries and the wish not to be a patient but a sportsman with a sporting problem who wants to be on the field as soon as possible. Also, doctors make the worst patients, so…