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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?

Roman Guggenberger: Yes, indeed. We have only just begun to implement dedicated training for sports-related injuries in our curriculum. So far, they form part of the general musculoskeletal (MSK) or orthopaedic imaging examinations that our residents have to read on a daily basis. However, we realise that there is increasing interest from our clinical partners in a more dedicated radiological approach. The Swiss Society of Musculoskeletal Radiology (SSSR) has therefore organised a joint meeting with the European Society of Musculoskeletal Radiology (ESSR) on sports imaging as recently as last April in Zurich with great success.


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?

RG: I work as a senior consultant and head of MSK imaging in the university hospital in Zurich (USZ) with quite a busy emergency and trauma centre. Most of the MSK-cases are related to acute trauma where only a minority are related to sports activity. I also work part-time in an outpatient site of our department where we mostly deal with orthopaedic problems. There, the proportion of sports-related injuries is certainly higher and comprises about 30% of all MSK cases.


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?

RG: As we are an Alpine country in Switzerland, most sports-related injuries are related to alpine activities. Certainly, skiing is among the most frequent ones, though the topography of the canton of Zurich is actually ideal for all kinds of sports. A lot of injuries are caused by playing football and certainly a rising proportion are due to bicycle/mountain bike accidents. With the increasing popularity of e-bikes we are also seeing more severe bike accidents, including in older patients.


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

RG: Due to our trauma setting, we see a lot of pelvic and spine injuries with all sorts of vertebral fractures. A state of the art dual-energy CT in the trauma unit allows for advanced post-processing in order to facilitate optimal triage of patients, e.g. virtual non-calcium images for better depiction of vessel integrity, e.g. in the cervical spine or monoenergetic extrapolations together with iterative techniques for optimal artefact reduction. Of course, peripheral joint injuries of the knees or ankles are very common as well and we very much rely on our MRI for adequate diagnosis.


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

RG: One has to differentiate acute trauma from more chronic conditions. In order to rule out fracture or any severe condition affecting vital organs such as the CNS, heart or lungs, CT is the most appropriate course of action. It is fast, comparably cheap and very efficient.

When it comes to more subtle, mostly not so acute or even chronic soft-tissue problems such as ankle sprain, ligament/tendon tears or muscle trauma, MRI offers the best diagnostic yield. In recent years we have gathered quite an extensive expertise in peripheral nerve imaging with MRI, not only in trauma cases but all kinds of plexo and/or peripheral neuropathies. We also do a lot of direct arthrograms and ultrasound (US) examinations, especially for our plastic and hand surgeons, although they have come up with their own ultrasound curriculum in recent years as part of their resident education.


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?

RG: I consider our role as an essential part of the puzzle, not the biggest one but certainly a decisive one. Interpretations of images are always dependent on the clinic of the patient. Sometimes we reach a different conclusion after talking to the orthopaedic surgeon or neurologist than we would have by simply looking and reporting imaging findings. Therefore, although very time consuming, interdisciplinary board discussions are an integral part of a radiologist’s life at the USZ. This is even more important as we offer the entire imaging armamentarium including nuclear imaging which at times leads to clinicians getting lost in finding the adequate indication for a certain modality.


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

RG: Conventional radiographs are usually taken in abundance as a first step and most of them are then interpreted by the referring trauma or orthopaedic surgeons themselves. However, they often seek help and advice from a radiologist when in trouble or doubt. In these instances, a radiologist may decide whether a patient undergoes further imaging work-up or is directly taken to the operating room. The same applies for follow-ups, where the majority of clinical decisions are made from the clinical status of a patient and additional conventional radiographs. However, soft tissue injuries usually need MRI or ultrasound for follow-up, and this is certainly done by radiologists. If the recovery phase of a certain condition does not follow the classic path, we are often asked to rule out any complication that would trigger an alternative therapeutic strategy.


ESR: Radiology is effective in identifying and treating sports-related injuries and diseases, but can it also be used to pre-empt them? Can the information provided by medical imaging be used to enhance the performance of athletes?

RG: This is certainly an interesting topic. A lot of work has been done on bone mineral density and bone quality assessment by imaging and a lot of techniques are being used to try to better elucidate the muscle function of an individual. MR-diffusion tensor imaging may allow radiologists to better characterise muscle texture and MR spectroscopy may potentially allow them to look at the biochemical constituents of muscle cells. Whole-body MR imaging may help to get a better picture of an individual’s body composition. The field is changing quickly and surrogate parameters from functional MR techniques together with patient related data may lead to a more precise assessment of an athlete’s general condition and potential. Nevertheless, MSK radiology is in large part based on traditional morphologic assessment of tissue compartments, e.g. volume, oedema and fatty infiltration of muscle tissue as surrogates for their function.


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?

RG: We have a new collaboration with the track-and-field sports event in Zürich, ‘Weltklasse Zürich’ where we will provide, together with our clinical physicians, full-time service for professional athletes during their entire stay in Zürich including training and competition. This collaboration is a result of our expertise and technical facilities that allow us to deliver high-quality diagnostic and treatment at any time. Much of the knowledge gathered in a professional athletic setting can be transferred to amateur settings. The ambitions and achievements there are by no means smaller than in the professional field.


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?

RG: This is definitely true, and I agree that many of our radiologic examinations would not be necessary if there was an adequate triage. However, it is not clear to me where it should come from. The medico-legal pressure on treating physicians is ever increasing and patients are becoming more demanding, placing even more strain on referring physicians. Furthermore, the healthcare system mainly rewards actionism, be it prescription of medications or imaging referrals. We need new endpoints in that treatment chain and new outcome measures that allow us to reward those measures that lead to a more efficient and sustained treatment. Of course, sports medicine is a highly competitive field and may not be suitable for that kind of thinking but therapeutic efficacy definitely has a role to play. Imaging is important in the triage of athletes in order to assess severity and rule out damage that would hamper early recovery. In that respect, imaging may help to prevent unnecessary treatment costs further down the road.


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?

RG: I think most professional athletes in general are quickly referred to MR examinations where ionising radiation is not an issue. Conventional radiographs of the body periphery are not that much of a problem either. CT imaging may of course be necessary and recent developments, e.g. tube voltage or -current adaptions to patient physiognomy or iterative reconstruction techniques have led to a marked reduction in radiation dose. Therefore, I think athletes at least in Switzerland do not have a substantially higher risk of developing diseases related to radiation exposure as compared to the general population. Radiation protection as an overall issue has been given high priority in our department and thus contributed to a marked reduction in the overall radiation burden.


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

RG: I do usually ride my bike to and from work which amounts to about seven hours of bicycle riding time per week. I also enjoy hiking a lot on weekends with my family where I usually have to carry one of our daughters on my back, and believe me, this is truly a hard work out.

Dr. Roman Guggenberger was born in Innsbruck, Austria where he studied medicine at the Medical University of Innsbruck. After obtaining full license as a general practitioner in Austria, he moved to Zürich, Switzerland where he finished his training in radiology at the Department of Diagnostic and Interventional Radiology. He has subspecialised in musculoskeletal and diagnostic neuroradiology with respective fellowships at the Balgrist Orthopedic Hospital and Children’s Hospital in Zürich. He obtained his ‘Venia Legendi’ at the medical faculty of the University of Zürich in 2016 and is now a senior consultant and head of musculoskeletal radiology at the Department of Diagnostic and Interventional Radiology in Zürich. Dr. Guggenberger is a member of the European and Swiss Society of Musculoskeletal Radiology as well as of the American International Skeletal Society. He is also a member of the Copenhagen based European task force on medication related osteonecrosis of the jaw. A strong focus of his scientific work is on recent CT imaging and metal artefact reduction techniques and cone-beam CT, as well as innovations in MR imaging of the musculoskeletal system with emphasis on peripheral nerve imaging. He has co-authored more than 50 peer-reviewed papers (including several review articles and book chapters), 40 conference abstracts, 20 invited lectures, and has won several national and international awards.

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