Select Page

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?

David Connell: Radiology training takes place in public hospitals which, other than trauma, do not usually see injuries in the sporting population. Athletes are most commonly treated at private musculoskeletal centres, and it is in this setting that interested radiologists may gain exposure at advanced training/fellowship positions.


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?

DC: I work in a dedicated musculoskeletal practice located in the bowels of a rugby and soccer stadium. Sports-related imaging and intervention make up 100 percent of our practice.


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?

DC: AFL (Australian Football League) football, rugby and netball account for most injuries, much more than say soccer, basketball or cricket. As the physical demands of these sports have changed, we see many more muscle injuries (particularly hamstring and calf) than before. In the last five years, we have seen more woman transition over to football and rugby. As a consequence, we are seeing many more injuries in the female population than before; these include muscle tears, shoulder dislocations and ACL rupture. The incidence of ACL rupture in AFL football for woman is nine times that of the male population, which is quite worrisome.


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

DC: As a diagnostic tool, MRI has superseded both ultrasound (US) and radiographs. For example, we typically perform 80 musculoskeletal MRIs per day, but perhaps less than 10 radiographs. There is a broad mix of all the joints. We are now quite confident in assessing muscle injuries and providing accurate information about when an athlete might return to play, and the risk of reinjury. For intervention, fluoroscopy has become redundant and we would typically perform 50–60 interventions per day under ultrasound or CT guidance.


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

DC: Imaging can detect almost all significant injuries in sport. When imaging is negative, this is most reassuring to the athlete and club that nothing terrible has occurred. This is particularly the case with head injury/concussion and muscle injuries.


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?

DC: Radiologists are able to provide an objective measure of a sporting injury. This has to be fed into the team and assessed in the context of clinical parameters. I often hear sports doctors saying that imaging is unnecessary or doesn’t change management – but I have yet to come across one brave enough to treat an elite athlete without an imaging assessment. Having said that, radiologists are a small cog in the machine, and it is important to remember to always treat the patient, not the scan.


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

DC: Our centre is a diagnostic and treatment facility for sporting injuries. We undertake diagnostic imaging, and then liaise with the referring sports clinician, surgeon and player. In many cases, we proceed to an imaging guided intervention. We often have the player returning for follow-up imaging to assess for healing of an injury and provide valuable information about return to play.


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?

DC: We are often asked to screen patients prior to the commencement of a season. For example, we have undertaken preseason ultrasound assessments of the patellar and Achilles tendons of entire football teams. The outcome is fascinating, as often asymptomatic players can be found with abnormal imaging findings. These players have a higher risk of developing symptoms in the course of the season; their training and load can be modulated accordingly to prevent injury.


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?

DC: Our centre is the premier sports imaging centre in Australia. We take on two fellows per year, and the knowledge they acquire can be disseminated throughout the country. One exercise allocated to the fellow is a ‘case of the week’, which involves describing an interesting case, explaining the anatomy, pathophysiology and literature review. This case is emailed to more than 2000 doctors per week. We also hold regular clinical meetings and review sessions.


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?

DC: Demand for sports imaging has sky-rocketed in Australia over the last decade. Government has recognised this and made attempts to limit access to imaging and intervention. For example, PRP (platelet rich plasma) and blood products no longer attract a government funded Medicare rebate; likewise general practitioners are no longer able to request knee MRI scans for people over 50 years. This seems a bit ageist to me (I’m 54 years old). ‘Oldies’ now have to see a specialist before getting a scan.


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?

DC: Our athletes are very rarely subject to radiation exposure, simply because almost all diagnostic imaging is performed with MRI or ultrasound. Likewise, a lot of interventions are performed with ultrasound. Even when we perform CT-guided injections for backs, our scanners have a very low radiation dosage.


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

DC: Yes! We have a gymnasium and swimming pool in our stadium. So, it is great to work out where the athletes (and potential customers) train! Athletes come into the centre and say, “Hey! Saw you in the gym this morning, looks like you were struggling a bit?” But they can also provide useful encouragement and training tips.

Dr. David Connell is a musculoskeletal radiologist and clinical director at Imaging Olympic Park, Melbourne. He is an Associate Professor in the Faculty of Medicine, Monash University, and also The Faculty of Sports Medicine and Research at La Trobe University. He is recognised as an expert in the diagnosis and treatment of muscle and tendon injuries. He has authored 107 publications, including book chapters, and has received funding in excess of one million dollars (including NHMRC grants). He has been an invited speaker to major meetings in 19 different countries. He is the past president of the Australasian Musculoskeletal Imaging Group, sits on the editorial board of five journals, and past examiner for the RANZCR. He acts as a supervisor for musculoskeletal fellowships and PhD candidates. He is an elected fellow to the Faculty of Sports & Exercise Medicine (UK). Assoc. Prof. Connell was a radiologist at the Sydney and London Olympics, and has a long history of imaging and treating elite athletes in New York, London and Australia.