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?
Kyung Nam Ryu: We have a dedicated national society, the Korean Society of Musculoskeletal Radiology (KSMR), which is under the Korean Society of Radiology (KSR). The KSMR is a group of specialists in musculoskeletal imaging and operates branch offices in each region, holding regular and occasional case discussions, training courses and seminars. These activities are not limited to sports and are treated as a part of musculoskeletal (MSK) radiology.
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?
KNR: As a professor in the department of radiology, my regular work includes interpretation of plain radiographs, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) of the extremities and spine. Sports imaging is included in my work and is not considered as a separate field.
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?
KNR: The most frequent injuries I have seen were caused by either football or basketball, in both professional athletes and amateurs. Other injuries that are increasingly common these days are caused by personal exercise, such as cycling, tennis and weightlifting. As more people are becoming engaged in physical activities these days, such injuries seem to be increasing. The most difficult thing for radiologists is that they cannot fully understand or be informed about the patients’ condition or history at the time of the injury. However, I do not feel that there is a particular type of injury that is too difficult or challenging to interpret.
ESR: Please give a detailed overview of the sports injuries with which you are most familiar and their respective modalities.
KNR: If a person who has not exercised regularly suddenly starts exercising on one occasion, it may cause muscle rupture of the lower limb or rupture of the Achilles tendon. In such cases, the muscle damage is caused by sudden change of direction rather than by contact. Most young people who practise sports extensively often visit medical clinics due to stress injuries in the lower extremities. Repetitive training increases the stress of a specific area, causing a reactive change or an incomplete fracture. The lack of sufficient rest seems to have an effect on such stress injuries as well. In the case of a basketball player, the stress injury most often occurs at the patellar tendon, and in the case of a gymnast, the wrist tendons.
ESR: What diseases associated with sporting activity can be detected with imaging? Can you provide examples?
KNR: Most abnormalities related to sports are assessed by MR examinations. With the development of equipment, MRI can now detect abnormalities in the microscopic areas. Basically, the diseases causing anatomical changes can definitely be found. You can also determine the rupture of ligaments, muscles, or small structures such as labrum, as well as the accompanying abnormal findings.
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?
KNR: A team of sports medicine will be configured in a variety of ways. In this team, the radiologist can provide information that will give quick access to the patient’s diagnosis, by indicating the type of imaging test the patient needs and the findings that can be obtained from each test. The radiologist can also guide the direction of additional tests if necessary. Radiologists are trained to look more comprehensively in the area of examination and diagnoses, compared to orthopaedics or surgeons. I think that radiologists can play the role of moderator in cooperation with other specialists.
ESR: The role of the radiologist in determining diagnoses with sports imaging is obvious; how much involvement is there regarding treatment and follow-up?
KNR: I think that the importance of radiology in the treatment of patients after diagnosis is overlooked. Diagnosis is also important, but in treatment, including surgery, imaging is important to know whether the treatment is effective or not. My personal opinion is that the treatment or follow-up requires more experience than diagnosis.
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?
KNR: My workplace does not run a specialised centre to treat sports-related injuries. I think those centres that are in charge of athletes can help to determine whether to keep the intensity of exercise by evaluating, with imaging, any anatomical abnormality if an athlete complains of fatigue in a specific body part.
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?
KNR: The demand for imaging surveillance is also increasing in Korea. These requests are made at the clinician’s unilateral request. In order to justify this, I think it is necessary to have a system that can more objectively judge the validity of the inspection.
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?
KNR: When an athlete is injured, he or she will undergo an x-ray, CT, ultrasound, or MRI examination. Unlike in a general illness, an athlete’s injury does not usually require consistent and repetitive tests in a relatively short period of time. In addition, x-ray examination is necessary if a fracture is present, but most patients without fracture will be examined by MRI and ultrasound, which do not use radiation exposure. Therefore, I think the possibility of illness caused by radiation exposure is low. As a way to limit the negative effects of overexposure, you may want to have a personal exposure record card so that the medical staff can refer to it during the radiation-based examination.
ESR: Do you actively practise sports yourself and if yes, does this help you in your daily work as MSK radiologist?
KNR: I personally exercise in the gym three or four days a week. I also go hiking on weekends if possible. Radiologists sit on a chair for a longer time than other clinicians and I think that exercise provides stamina to focus on the reading.
Prof. Kyung Nam Ryu is chief of musculoskeletal imaging at the department of radiology of Kyung Hee University Hospital and full time Professor at Kyung Hee University, college of medicine in Seoul. He also served as planning director at Kyung Hee University Hospital in 2010–2011. He is interested in joint and musculoskeletal imaging and notably received training at the University of California, San Diego in 1995–1996. Dr. Ryu has authored over 226 papers and five book chapters and given 110 invited lectures. He is a former President of the Korean Society of Musculoskeletal Radiology and former chief editor of the Journal of the Korean Society of Ultrasound in Medicine, where he also served as chair of general affairs. He is a former chair of the planning committee of the Korean Society of Radiology and has been a member of the International Skeletal Society since 2000.