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?
Igor Borić: Sports imaging is not a subspecialty in Croatia much like in other European countries. As part of their training in radiology, a resident passes part of the musculoskeletal radiology curriculum where they also acquire a basic knowledge of sports imaging. To deepen knowledge on sports imaging, the musculoskeletal section of the Croatian Society of Radiology organises courses and workshops where radiologists take part in sports imaging focused courses organised by the European Musculoskeletal Society Sports Subcommittee.
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?
IB: I work at a private hospital for orthopaedics and sports medicine. I am also a member of the Croatian Olympic Committee’s Health Commission, the chief physician of the Croatian Tennis Association, and my hospital is also the official hospital of the Croatian Football Association. I see a large number of Croatian and international athletes for my work. My daily work is mostly related to the imaging of sports-related injuries.
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?
IB: Professional sports in general bring a lot of injuries. Among all sports, contact sports (ice-hockey, handball) or sports where athletes move at high speed (skiing, football, motorsports) bring the greatest number of severe sports injuries
ESR: Please give a detailed overview of the sports injuries with which you are most familiar and their respective modalities.
IB: The knee and shoulder are two of the most common joints affected in sports injuries. Ligamentous injuries are the most common, followed by meniscus and glenoidal labrum injuries. Today, reconstructive surgery of these injuries provides excellent results, and an almost entirely complete recovery is common. The most severe problem, however, is cartilage damage as there are still no satisfactory methods for treating this. Radiology is indispensable in the diagnosis of all these lesions, and MRI plays the most important role in their diagnosis.
ESR: What diseases associated with sporting activity can be detected with imaging? Can you provide examples?
IB: Because of the high sensitivity and specificity of imaging methods (radiography, ultrasonography, computed tomography, magnetic resonance), the possibility of detecting bony or soft-tissue injuries is tremendous. Imaging plays an important role, whether it is acute or chronic injury or even overuse syndrome. With modern radiological technology, one can make miraculous findings; still, the most important tools are the precise eyes of an experienced musculoskeletal radiologist.
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?
IB: Care of an injured athlete is indeed teamwork, involving experts from different specialties. What is the place of the radiologist in that team and what is their role? The role of a radiologist is very important in the entire treatment process of the injured athlete. The first task of the radiologist is to detect an injury and establish a reliable diagnosis. Knowledge of the mechanism of injury and the specificity of the particular sport will also dictate the selection of the best diagnostic method of use (radiography, CT, US, MRI). Establishing a diagnosis does not complete the work of a radiologist. Based on the radiological diagnosis, it will then be decided which type of treatment is necessary for the injury. Radiologists follow up on the success of the treatment and the effects of rehabilitation. Ultimately, the radiologist will assess when morphological changes are in such a condition that an athlete is able to return to sporting activities. Of course, the radiologist will recognise the underlying morphological changes and development anomalies that need to be remembered to prevent future injuries. Therefore, the role of the radiologist is to detect injuries, set up a reliable diagnosis, advise how best to treat the injury, follow up on the success of treatment and rehabilitation, and evaluate when the treatment is complete, resulting in an athlete’s return to sporting activity. In professional work with athletes, each expert has an equal role as part of the team, and this needs to be insisted.
ESR: The role of the radiologist in determining diagnoses with sports imaging is obvious; how much involvement is there regarding treatment and follow-up?
IB: As I pointed out in my previous answer, the radiologist must have an advisory role in choosing the optimal treatment method, but also in monitoring the treatment success, whether treatment involves a surgical procedure or physical rehabilitation method.
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?
IB: Careful radiological examination may detect slight deviations from normal organ morphology (anatomical variants) that may lead to tissue damage or injury during sporting activity. The task of the radiologist is to point the athlete to such anomalies, as these damages and injuries can be, in most cases, avoided by a change in technique and behaviour.
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?
IB: As the official hospital of the Croatian Olympic Committee, Croatian Football Association, Croatian Tennis Association, and many other clubs in different sports, my hospital is tasked and obligated with providing top medical care to our athletes. Such top medical care is based on principles of personalised medicine, and for the implementation of such kind of medicine, it is necessary to use top quality medical equipment. This attracts top athletes and top experts to our hospital, allowing us to get a reliable and prompt diagnosis. Experience in treating top athletes, the application of advanced imaging equipment, and evidence-based medicine improve the quality of treatment for all our patients.
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?
IB: It is true that the demand for imaging studies has been steadily rising over the past decades, even in sports medicine. This, in any case, has a negative impact on healthcare budgets. However, a large number of imaging procedures have improved diagnostics. Now, we are able to establish a reliable diagnosis faster and more easily, which leads to prompt and effective treatment for a speedier recovery. This is the way to bring savings to healthcare budgets. Knowledge of the possibilities and limitations of each radiological method further reduces costs when selecting the modality that will be most optimal for managing sports injuries. Use of widely accepted protocols and algorithms allows for the best use of available radiological methods.
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?
IB: Exposure to ionising radiation is always a risk associated with the development of radiation-induced diseases. However, modern radiology uses advanced devices where exposure to radiation is minimised. In addition, ultrasound and MRI, whose methods are not based on harmful ionising radiation, are increasingly being used in diagnostics. Of course, the benefit of using ionising radiation and the harm to the patient should always be taken into account.
ESR: Do you actively practise sports yourself and if yes, does this help you in your daily work as MSK radiologist?
IB: I practise recreational sports in accordance with my age and my occupation. Of course, sport helps me a lot. First of all, as an MSK radiologist, I am familiar with various types of injuries and their mechanism, which helps me to prevent such injuries. Secondly, sport keeps me fit and makes me healthier and more capable of hard work.
Dr. Igor Borić, MD, PhD is Professor of Radiology at the University of Split School of Medicine, University of Rijeka in Croatia and University of Mostar, Bosnia and Herzegovina. He is Hospital Director and Chairman of the Department of Radiology at the St. Catherine Specialty Hospital in Zagreb. His subspecialisation is in MSK radiology and he is Chairman of the Sports Subcommittee of the European Society of Musculoskeletal Radiology as well as Chairman of the MSK Section of the Croatian Society of Radiology and a member of its board. His main interest is in sports imaging, imaging of trauma and paediatric MRS radiology. He has authored or co-authored more than 50 peer-reviewed publications (including several book chapters) and has given numerous invited lectures, tutorials and refresher courses at national and international meetings.