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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?

Ronaldo Magalhães Lins: Here in Brazil, there is no special focus on sports imaging during a radiology residency, but the musculoskeletal area handles imaging of several kinds of injuries. When radiologists have a special interest in sports medicine, they must engage in specific courses regarding such matters. Most courses are post-graduation lato sensu in sports medicine, in which the radiologist will have access to clinical, nutritional, physiological, biomechanical information and much more. These courses are taught by doctors, who are specialised in sports medicine, at some universities here in Brazil and abroad.


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?

RL: I work at my private practice, at a school that provides courses in medicine, and for football teams, including the Brazilian men’s national football team. I spend most of my time at my clinic, and the schedule is partly sports imaging. The same occurs at the Centre of Ultrasonography Training of Sao Paulo. At football training centres, my time is fully dedicated to sports imaging. Being part of a multidisciplinary team, we discuss each athlete’s case together with a practitioner in sports medicine – usually an orthopaedist –, a physiotherapist, a physical trainer and a physiologist. As a radiologist, I perform not only diagnosis based on imaging, but also, whenever necessary, guided interventions in athletes.


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

RL: When I started my career in sports medicine, some sports caused the most varied injuries, for example, football, tennis, athletics and Olympic gymnastics. Today, sports generally produce high-performance athletes who, regardless of which sport they practise, are much more prone to injury. Imaging techniques offer increased sensibility to diagnose structural injuries caused by sports practise, and I don’t believe that certain specific injuries are more difficult to confirm. The complicated task is to evaluate the clinical importance of the imaging’s findings, and when that alteration needs to be addressed during the follow-up of an injury. As we know, an injury tends to remain visible on imaging even after clinical signs already demonstrate functional recovery. This is especially true with MRI, an extremely sensitive modality.


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

RL: Because I work a lot with football, I mostly see muscular injuries and sprains. Regarding knee sprains, the most frequent are meniscus and ligament sprains. Ankle sprains tend to tackle lateral ligaments, especially the anterior talofibular ligament, in which they present in 70% of isolated cases.

Regarding muscular injuries, we have both functional injuries, such as fatigue oedema and late muscle pain, and structural injuries, such as ruptures due to elongation. In the latter, we have the involvement of hamstrings due to an abrupt switch of speed, owing to the different style in which athletes play these days. If we compare football ten years ago, when players used to run 4–6km per game and at low intensity, with what football is today, with players running 10–12km at high intensity for 40% of the game, we can see why the injuries are more prevalent, especially in the thigh posteriors, the group of muscles activated during run-up. All pathologies induced by repetition, either macro or micro traumatic, are very well diagnosed with imaging methods. Some examples are articular injuries, such as osteoarthritis due to mechanical use of the articulation, tendinopathies, the muscular and the ligament injuries, and bone fractures from stress or trauma.


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?

RL: The radiologist is essential to optimal patient management within the medical team. To all the radiologists who want to work in sports imaging, I would like to highlight that the clinical thought is extremely important to assist your performance. Therefore, we must all be great practitioners and not only imaging professionals. We should also seize the interaction with other professionals, such as orthopaedists, physical therapists, physicians and physiologists, to improve ourselves every day. If we are faced with a sports injury and have a good clinical base, the correlation of the imaging and the clinical suspicion adds up quite a lot to our diagnosis accuracy.


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

RL: The radiologist is the specialist who helps define a diagnosis through imaging when a clinical suspicion is encountered. If necessary, it is possible to guide intervention with imaging, in which case the radiologist will be there to assist. In sports medicine, radiologists are very much involved because they evaluate the follow-up of athletes’ recovery throughout their return to practise. During treatment, guided interventions may be required to improve the result, and there is no better method to do so than imaging.


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?

RL: Imaging is not so much used to prevent injuries, but since we work in a multidisciplinary team, we use radiology to assist the performance and follow-up of athletes. As an example, we can use imaging to detect asymmetries in a muscle or even diagnose signs of a degenerative tendon that could evolve to a functional deficit for the athlete.


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?

RL: Yes, I was invited to be a part of the Brazilian men’s national football team, which was a benchmark in sports imaging in Brazil. This experience in high excellence centres has made me grow professionally because the evaluation of an athlete from a multidisciplinary point of view is much more efficient than just the imaging part alone. This has been my argument in daily interactions with every type of patient, seeking better diagnosis and efficient treatment.


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?

RL: Advances made in equipment have been perfecting imaging quality and the demand for examinations in sports imaging has increased, especially due to imaging’s sensibility to diagnose sports injuries. These days it’s not only possible to detect acute injuries, but also minimal lesions that have no clinical significance yet but could turn into a prejudice for the athlete in the future – and these are the ones we detect to treat in advance. Interaction with other specialties is very important, mainly because it contributes to their knowledge of each imaging method, therefore improving adequate prescription and avoiding unnecessary costs.


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?

RL: Nowadays, this is no longer a concern for two reasons. Firstly, because the equipment that does use ionising radiation comes with filters that significantly reduce the risk to the athlete. Secondly, and perhaps most importantly, because there are other imaging modalities that can be used for diagnosis that do not use ionising radiation at all, such as magnetic resonance imaging (MRI) and ultrasound. We use these modalities the most.


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

RL: I must say I am a bit sedentary. I practise low-performance activities such as bike riding and muscle training, but I realise I should be more efficient as it’s important for my professional daily routine.

Prof. Ronaldo Magalhães Lins, MD is the radiologist of the medical board for the Brazilian men's national football team, being responsible for imaging analysis during pre-season, the World Cup 2018 and the American Cup 2019. From 2012 to 2018 he was Vice-Chairman of the Brazilian College of Radiology (Colégio Brasileiro de Radiologia e Diagnóstico por Imagem, CBR) and is currently on the commission on ultrasonography of the same entity. Prof. Lins teaches classes on musculoskeletal ultrasonography and image-guided interventions in sports medicine at the Centre of Ultrasonography Training of Sao Paulo (CETRUS). He has a private practice in Belo Horizonte. An active researcher, he is assistant professor in the International Course of Regenerative Medicine, certified by UNICAMP – SP and the American Academy of Regenerative Medicine (ORTHOREGEN), in which he investigates the use of regenerative substances, such as plasma rich in platelet and mesenchymal stem cells. He has authored chapters on sports imaging in two released books as well as several reviewed articles and has presented numerous lectures, both nationally and internationally.

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