Portugal / Dr. Lina Melão

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?

Lina Melão: In Portugal, residency and fellowship training programmes are based on a subspecialty model and try to place all focus on musculoskeletal radiology. Most of these programmes are in trauma referral centres in a publicly funded healthcare system, in which athletes only go to for assistance in major or acute trauma, limiting sports-related injuries to this setting. Therefore, most of the training for interested radiologists on sports imaging is achieved at courses, conferences or fellowships abroad.

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?

LM: I am radiologist at both a public hospital and a private practice, and split my work between these two completely different perspectives of medicine.  At the University Hospital, imaging procedures are performed in government-funded facilities that operate on fixed funding models where often the demand for imaging procedures exceeds budgeted capacity, resulting in outpatient waiting lists. Sports imaging, apart from acute trauma, is pushed to the side. At the private practice, I work with orthopaedic sports doctors responsible for the national female volleyball team, professional hockey and football players, and other elite professional athletes. So, I would say that sports imaging makes up an important part of my work schedule.

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?

LM: Football is the most common source of sports injuries in Portugal. It is a physically demanding contact sport and injuries range from the ordinary, relatively benign, low-grade muscle strains to potentially career-ending ligamentous injuries. Recently, there was a paddle tennis boom, and with it, a wave of racquet sports injuries regarding mainly the upper limb, challenging the predominance of football-related lower limb injuries. In my opinion, the greatest challenge in sports imaging nowadays is timing!  There is a need for speed; the faster you deliver the accurate diagnosis, the more quickly effective management begins. Elite sports operate under significant time pressures, where every minute counts, timely imaging and diagnosis can allow athletes to undergo treatment or to begin an accelerated recovery process and return safely to competition. In more severe muscle injuries associated with haematoma, the first few hours after the injury, it may be difficult to distinguish blood from normal muscle. Therefore, an acute examination of the muscle at the pitch side is very unlikely to reveal abnormalities.  We must know our limitations and use them wisely to keep our place as a team player in the health care of athletes.

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

LM: There are essentially two major types of sports injuries: acute traumatic and chronic overuse. In the first group, muscle injuries are very common and almost transverse to all sports. The hamstrings represent the most often-injured muscle group. The radiologist plays a crucial role in determining the extent of the injury and advising athletes on their expected duration of inactivity. The distinction of involvement of the central tendon is highly significant. Usually within 24 hours, the extent and size of the rupture can be well assessed using ultrasound, and the differentiation from oedematous adjacent muscle is better assessed using ultrasound than MRI.

Another very common acute ligamentous injury is, of course, anterior cruciate ligament rupture that usually occurs in high demand sports like football, basketball or volleyball, with very rapid change of movements. Female players have a greater tendency for these types of lesions. They are rarely isolated, normally occurring with other ligamentous, meniscus or osteochondral injuries. MRI can identify all primary and secondary signs of an ACL rupture which makes it the main modality of choice when suspected. Overuse injuries are more indolent but sometimes more incapacitated and make the athlete more prone to succumbing to a second injury. Athletic pubalgia is chronic groin pain during activity and very common in professional football players. This pain syndrome was formerly called ‘sports hernia’, and it comprises multiple causes affecting the pubic symphysis region: injuries to the rectus abdominis insertion, origin of the hip adductor tendons, and the pubic symphysis. MRI has a higher sensitivity and specificity in this diagnosis. Stress reactions and stress fractures are also constantly present in my daily practice. Stress fractures usually occur after a recent change in training regimen has taken place. When athletes are subject to change in training intensity, type of training or training circumstances (new shoes, other training surface etc.) they are at an increased risk of developing a stress fracture. Muscle fatigue can also play a role in the occurrence of stress fractures, as fatigued muscles stop absorbing impact forces, placing greater strain on the bones. Stress fractures are most common in the weight-bearing bones of the lower extremity, but they can occur in every bone that sustains hard impact.

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

LM: Chronic overuse injuries especially affect lower limb, obviously depending on the type of sport, and the most common of these are Achilles and patella tendinopathies, plantar fasciosis and stress injuries of tibia and foot/ankle. Acute muscle injuries, particularly hamstring and calf muscles, are more common in running sports. Acute ankle or knee ligament injuries are mainly seen in contact sports.

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?

LM: Multiple professionals are involved, particularly at the elite level, and working as a team is important to provide an excellent and efficient approach. Patient care is a team sport, and the interaction between the radiologist and the treating practitioner is vital to ensuring quality. The radiologist forms an important part of the team, working in conjunction with the sports medicine physicians and surgeons, who are typically the primary provider for the patient. The radiologist offers an impartial interpretation of imaging findings, free from preconceived impressions, and has a clear understanding of different imaging modalities and what each might add to a particular diagnostic problem. They can also perform image-guided interventions, which are very important in the sports population. However, availability is the key. One approach is to create a consultation line for referring physicians to call that is answered directly and conveniently. Radiologists must be available to review a study, arrange an urgent procedure, provide professional guidance on the work-up of a patient, or even clarify a report, these interactions with referring colleagues are an opportunity to build strong peer-to-peer relationships.

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

LM: Interventional MSK procedures are becoming increasingly popular. These range from simple minimally invasive to more advanced procedures. Straightforward procedures include MR arthrography, spinal epidural injections, and ultrasound-guided procedures. More advanced procedures include vertebroplasties, and image-guided percutaneous discectomy for lumbar and cervical radiculopathy. These are the breakpoints, the grey area, where physicians and surgeons also enter the picture. Working as a team, and for the best interest of the patient, we must all know our strengths and weakness and make the best of it. Therefore, our job as interventional MSK providers may adapt depending on the group we work with.  Nevertheless, the need for MSK procedures must be accompanied by an increased clinical role of radiologists to become active partners in the clinical management of patients. Radiologists must be willing to take on clinical responsibilities: reviewing patients in clinics to determining the suitability of a procedure and potential contraindications, as well as being willing to manage procedure-related complications.

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?

LM: The consequences of sports injuries can be very serious and suspend athletes for a long time. Although it often seems like these injuries happen in a split second, they can also be the result of overuse and loads that weaken an athlete over time. This stress can be detected with imaging and injuries prevented before they happen. As a result, we can see stressed bone reactions before stress fractures and can diagnose tendinopathy prior to tendon rupture.

Many friction syndromes can be appreciated and managed accordingly, sometimes with simple measures and procedures, promoting superior performance and results for the athletes.

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?

LM: No, I do not practise in one of these elite centres, but they often have the essential ingredients to create successful sports practice, performing a rapid assessment, having a strong commitment from all participants, and fundamental and consensual management.

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?

LM: Transparent and suitable access to image services is a daily challenge for radiologists practising in a publicly funded healthcare environment, where budgetary constraints can result in long imaging waiting times and accepting urgent referrals is potentially viewed as providing preferential access. Best practice in these scenarios is to assemble all interested partners (MSK radiologists, orthopaedic surgeons, sport medicine physicians, a primary care/family medicine physician, and physiotherapist) to a committee to approve guidelines of urgency for the most common clinical circumstances.

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?

LM: Actually, I don’t think this is an enormous problem for athletes, most of them first undergo ultrasound and MRI. Nevertheless, we must always be concerned with overexposure and try our best to minimise it. Reducing x-ray views to a minimum and using low radiation CT scans when necessary are some of the means we have to manage exposure.

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

LM: I was a competitive swimmer during my youth and now am a casual runner. All my children are federated athletes. Sports activity is a very essential part of my life. Athletes have different motivations than the general population and we must understand that, even if some decisions are not in their best medical interest. Athletic careers are short and competition is high. Living this reality helps to comprehend their world.