Finland / Dr. Ia Kohonen

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?

Ia Kohonen: Sports imaging is a special focus within musculoskeletal radiology in Finland. Sports imaging education for residents and musculoskeletal radiology trainees is a little bit challenging because most athletes are treated and imaged in private sector hospitals due to insurance. In addition to case-based learning in a hospital, the residents and trainees receive education at national and international courses and congresses.

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?

IK: I work as a musculoskeletal radiologist at the Turku University Hospital, in Finland. I practise very little sports-related imaging in my daily practise. My work at the hospital consists of imaging degenerative and inflammatory bone and joint diseases as well as musculoskeletal tumours and traumas. Additionally, I take biopsies and do different kinds of interventions. I provide multidisciplinary radiology reviews on tumours, trauma and arthritis boards. Furthermore, I teach residents, trainees and medical students. Beyond the normal working day, I do shifts in a private hospital to get in touch with sports imaging.

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?

IK: Different kinds of injuries are quite common in contact sports, especially at the professional level. For example, ice hockey is very popular in Finland, which often comes with numerous ice hockey related injuries; shoulder and elbow, knee ligaments, muscle and tendon bruises, strains and head injuries. Athletes at the professional level feel pressure to make a fast recovery and return to the same performance levels. In these cases, medical imaging is more readily performed. On the other hand, nowadays there are more middle-aged and older amateur athletes than ever before. These athletes have more age-related diseases (osteopenia, arthrosis, dizziness) than the younger ones and their risk of injury is higher.

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

IK: Achilles tendon complaints (ultrasound), os trigonum syndrome and Haglund (MRI), tennis leg (ultrasound), jumper’s knee (ultrasound, MRI), ligament injuries in knee and ankle (MRI), patellar instability (MRI), rectus femoris strain (ultrasound, MRI), hamstring injuries (MRI), FAI (radiography, MRI), fatigue fractures in lower leg and spine (radiography, MRI), compartment syndrome (MRI), tennis and golfer’s elbow (MRI) and skier’ thumb (MR).

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

IK: Stress osteopathy and fatigue types of stress fractures in numerous places including the hip, knee, metatarsal bone and lumbar spine are common among professional and non-professional athletes. They can be detected by radiographs or MR imaging. Lower leg compartment syndromes and shin splints can also be detected by MR.

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?

IK: The musculoskeletal radiologist is an equal member of a multidisciplinary team. Good co-operation between team members is of course important. It is almost essential that everyone in the team knows each other personally. Consultation and discussion must be made as easy as possible.

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

IK: The clinician is responsible for treatment but sometimes suggestions concerning follow-up are given by the radiologist. Of course, in challenging cases, both the clinician and radiologist may discuss the best treatment protocol for the athlete.

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?

IK: For example, if a stress osteopathy is detected on MR images, a break from training would probably prevent fracture lines from appearing.

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?

IK: As previously mentioned, I work shifts in a private hospital where I meet most of my athlete patients. In Finland, it is possible to work both in the private sector and at the University Hospital, which makes it quite easy to share knowledge between these two places. On average, the quality of imaging equipment at the University Hospitals is very good, as good as or even better than in private hospitals.

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?

IK: There is a trend in medicine towards more imaging and as a result the demand for imaging studies has increased in sports medicine as well. It is important to find out if the athlete has severe enough injuries that would warrant an operation. It is cost-effective if the right treatment is done at right time point.

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?

IK: Ultrasound and MRI are excellent imaging modalities in many cases when imaging sports-related injuries. Radiation is not a problem when using these modalities. When imaging peripheral bones and joints with radiographs, it is not usually problematic either as the radiation dose is so low. CT is more challenging because of the markedly higher radiation dose. When considering CT, every case must be evaluated thoroughly – is this study necessary and if so, it should be performed with the lowest amount radiation possible.

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

IK: I go jogging and exercise at the gym. My own training, however, is not very target-oriented and far from professional, so it does not help me a lot in my work with athletes. My knowledge of sports injuries is based on literature, seminars and congresses, senior colleagues’ counselling and the patients themselves.