Ireland / Dr. Patricia Cunningham

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?

Patricia Cunningham: In Ireland, sports imaging is part of musculoskeletal (MSK) radiology and is performed mostly by radiologists with MSK training. There is no special focus on sports imaging for trainee radiologists, but they would be exposed to common sporting injuries during their MSK training/modules. There are no dedicated training courses for radiologists interested in sports imaging, but most MSK radiologists attend international meetings and courses to learn or maintain skills.

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?

PC: I work in two teaching public hospitals, neither of which have radiology trainees, but they do have trainees in other specialties. In Ireland, public hospitals have some private practice attached, and I work in this sector as well. I believe MSK imaging and procedures including sports take up approximately 60% of my clinical work.

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?

PC: The most commonly played sports in Ireland are football, rugby and our national games of hurling and Gaelic football. These generate most of the injuries that require imaging. The injuries do vary between the sports, for example, hand and finger injuries are very common in hurling as this is played with a hurley stick; often radiographs are all that is required. Gaelic football has similar injuries to football, with groin, hamstring and knee injuries common. Besides, as Gaelic football allows catching of the ball, there are shoulder injuries similar to those in rugby. In the last decade or so, the change I have noticed most is the pattern of muscle injuries in the pelvis/thighs with less hamstring injuries and more groin injuries.

Muscle injuries, I think, are the most challenging for several reasons. The extent of the injury is often over or under-diagnosed clinically before imaging occurs, and this can affect the clinical team and the player in terms of mental and physical response. The return to play time has become such an important feature of imaging that it adds extra pressure to the reporting radiologist, potentially causing some conflict with other members of the medical management team. Pressure can also come from players themselves in terms of wanting to return as early as possible, which may cause some tension or disagreement between the radiologist and the sports physician/team doctor.

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

PC: In my practice we see a large amount of knee injuries (meniscal, cruciate and MCL), ankle injuries, predominantly ligaments, shoulders (dislocations with sequelae of same), hand injuries (particularly fractures in hurling and UCL injuries) and groin pain (osteitis pubis, adductor/gracilis/rectus abdominis injuries, labral tears). MRI is our test of choice for nearly all sports injuries apart from obvious fractures and hand injuries. All knee, shoulder, hip, groin and muscle injuries are evaluated with MRI. Shoulder and hip MR arthrography are reserved for those who have indeterminate non-contrast MRI for evaluation of labral and cartilage injuries or who have a high level of suspicion for these injuries from the outset. Ultrasound is often the first test for tendon injuries such as Achilles, peroneal and wrist tendons, with MRI reserved for more detailed analysis as necessary.

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

PC: It is not uncommon to image players for a specific injury and find incidental pathology. This is similar to the general population and not really specific to sports players. The age profile of the individuals commonly imaged is also relatively young, making other diseases less likely. However, with increased focus on health and fitness in the community at large, we are seeing more older people for sports imaging (especially runners) who are more likely to have an incidental finding. On occasion, someone may present with back or pelvic pain presumed to be due to sporting injury but may be inflammatory arthropathy as this would be commonly seen/diagnosed in young adults. Imaging performed for symptoms thought to be related to a sports injury rarely diagnoses a tumour.

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?

PC: Radiologists are an integral part of the multidisciplinary team managing sports injuries. I would say the radiologist works closest with the sports physician/team doctor, and most decisions would be made in this realm. I see major roles for the radiologist as follows; confirming an accurate diagnosis by the most appropriate imaging modality, helping to inform decisions regarding management including return to play, performing certain procedures/injections and to a lesser extent helping with pre-participating assessments. Generally, each team member works well for the best outcome of the player, but occasionally there can be conflict particularly in relation to return to play as mentioned earlier. Many sports physicians are quite skilled in using ultrasound and interpreting MRI, and this sometimes leads to discussion/dispute when there is a difference of opinion with the radiologist.

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

PC: As I mentioned above, I feel the role of the radiologist incorporates performing certain procedures/injections and evaluating return to play. The latter in particular is a growing area with healing being evaluated with imaging during the course of rehabilitation rather than just initially or at the end.

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?

PC: I do not have much experience with screening and pre-assessment. In principle, it is a good idea, but with existing limited resources it would be difficult to implement. Imaging would be helpful in diagnosing cases of tendinopathy/partial tendon to help prevent complete tears which would, for example, have significantly higher morbidity. I think a very important role is played by our cardiac colleagues in trying to identify those at risk of sudden cardiac events during sport.

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?

PC: I do not work in a specialist sports centre, but many of the injuries that are seen in amateur and ‘weekend warrior’ type sports are the same as those in professional athletes in more elite centres. All knowledge and experience gained in these centres can be applied to a more general setting. The increased number of injuries seen in a specialist centre allows expertise and skill to develop quickly, and this can then be disseminated more widely.

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?

PC: In my practice, the majority of sports imaging costs are covered by insurance with the sports clubs as long as the injury took place during club activity. This takes the burden away from the individual. However, in Ireland as elsewhere, there are limited resources, especially in terms of MRI, the modality that is relied upon most in sports imaging. Like all imaging, good clinical assessment and close cooperation with the other members of the medical management team can help optimise the resources available.

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?

PC: The risk from exposure to radiation from medical imaging is very small. As I alluded to earlier, most sports imaging relies on MRI and ultrasound, which have no ionising radiation. The small doses of radiation used in image-guided procedures and radiographs do not pose a significant risk, and of course all precautions are taken (as with everybody) to keep the dose as low as reasonably achievable.

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

PC: I used to participate more when I was younger, but I have a keen interest in sport generally. I think this does help in terms of understanding injury mechanics and makes me more empathetic with the players.