Austria / Dr. Klaus Friedrich

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?

Klaus Friedrich: As the head of musculoskeletal imaging at the Austrian Roentgen Society (Österreichische Röntgengesellschaft), it is my goal to promote the subspecialisation of musculoskeletal radiology. However, this subspecialisation is often seen as a luxury in Austria, a small country with many small hospitals and even big university hospitals that have staffing problems. Therefore, we are happy to cooperate with larger partners like the International Skeletal Society (ISS), the European Society of Musculoskeletal Radiology (ESSR), and with the German Society for Musculoskeletal Radiology (DGMSR), which provide radiology training in the form of conferences and fellowships. Additionally, there are special MSK courses for interested radiologists in Austria that are also very popular and thus mostly overbooked.

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?

KF: I work at the Medical University of Vienna Hospital and also in a private practice. Sport-related imaging makes up a large part of my regular work; however, as a musculoskeletal radiologist, I also see a lot of degenerative and metabolic diseases as well as inflammatory joint afflictions.

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?

KF: In Austria, as in many other countries, football causes more injuries than any other sport. Alpine skiing, the national sport in Austria, has a high frequency of injuries associated with it as well. For both, MR imaging of the knee in particular is often required. Skiing technique has changed dramatically over the last 20 years. Carving skies are a lot easier to handle than classic skies which were much longer and required more skill and technique to use safely. Carving skies allow beginners to go faster than they should. This might also be one of the reasons why, although the overall rate of skiing-related injury has decreased, we diagnose more shoulder injuries in skiers than before. From my experience, the greatest challenges in diagnosing sports-related injuries come up in situations that restrict us in the selection of the optimal imaging modalities; for example, in cases of contraindications for the use of MR imaging or in cases which demand higher radiation protection, like in children or pregnant women. However, these are essential challenges that keep us excited about our daily work.

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

KF: About half of all skiing injuries are fractures. Thus, an x-ray is still the first-line imaging modality of choice in most cases. In skiing, the knee is the most common site of injury with ligamentous sprains of the anterior cruciate ligament (ACL) and/or medial collateral ligament (MCL) being most commonly affected. For knee injuries, our initial radiological examination is an x-ray, often followed by an MRI; for some cases, CT and ultrasound can be very helpful. Also, head contusions and concussions, glenohumeral dislocations, and sprains to the wrist and hand are quite common. The most common injuries involving the shoulder include rotator cuff injuries, anterior glenohumeral subluxations and dislocations, acromioclavicular sprains, proximal humeral fractures, and clavicular fractures. Similar to the knee in general, we start our radiological examination in patients with shoulder injuries with an x-ray; many patients also need an ultrasound or an MRI thereafter. Additionally, CT might be necessary for preoperative planning in fractures or for the exact evaluation of Hill-Sachs-Lesions. Some authors suggest that ‘skier’s thumb’ or ulnar collateral ligament tear, may in fact be the most common skiing injury but often goes underreported due to the patients’ perception of its lack of severity. In skier’s thumb we want to rule out osseous avulsions with x-rays while the ligamentous situation might be evaluated with ultrasound or MRI.

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

KF: One of the best known diseases associated with sporting activity, detectable with imaging, is Osgood-Schlatter disease, a chronic overuse injury due to repeated microtrauma at the insertion of the patellar ligament to the tibial tuberosity. Another example would be Sever’s disease, also known as calcaneal apophysitis; both occur in children/adolescents with the latter clinically diagnosed.

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?

KF: I prefer to consider the patient as the most important part of the team; this is not only a flowery phrase as, especially in musculoskeletal radiology, we find pathologies that are asymptomatic in almost every patient, thus the patient must clearly communicate with the attending physicians so they know which findings are of clinical importance in the moment. The radiologist plays an important role in the team of clinicians as only with a clear diagnosis will the patient receive adequate treatment.

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

KF: This very much depends on the team of colleagues one works with. I know that Austrian MSK radiologists specialised in ultrasound also do a lot of ultrasound-guided interventions in sport related injuries, for example with platelet rich plasma, and have very good results. The referring clinicians in those cases do not see the radiologist as a competitor, but as a supporting partner in the management of the patient.

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?

KF: Yes, radiology can also be used to pre-empt sports-related injuries and diseases. In football players, we can diagnose subtle finding at the symphysis and its muscle origins and attachments that can result in severe muscle injuries, avulsions, and chronic instability if not anticipated. Imaging modalities can also be used to make the effects of training on muscles measurable.

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?

KF: The best way to use this knowledge is to convert the clinical data into studies that make findings measurable. The results from these studies can then help other radiologists to improve their diagnostics. Another additional way would be to establish more MSK fellowships so young radiologists in training can visit those centres, benefit from each other and bring that knowledge to their home hospitals/countries.

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?

KF: Yes, the demand for imaging studies in sports medicine has indeed increased, especially for MR imaging. In Austria, not only referring clinicians, but often also the patients themselves demand MRIs. They want to know their exact diagnosis, immediately. For the last few years in Austria there have been guidelines for referring clinicians that demonstrate whether any or which radiological modality is indicated in order to answer a clinical question. However, this cannot stop a patient from having an exam, especially if the patient decides they want to pay for the examination privately.

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?

KF: X-rays and at times CT play an important role in the imaging of sports-related injuries or diseases; however, MRI and increasingly ultrasound are very powerful imaging modalities, without radiation, that are increasingly being employed.

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

KF: Yes, I enjoy skiing, tennis, and fitness training a lot. It helps me to compensate daily work-related stress and thus to increase my general capacity to work. However, I am very happy that it is not necessary to experience all sports-related injuries oneself to diagnose them correctly ;-).