Thailand / Dr. Suphaneewan Jaovisidha

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?

Suphaneewan Jaovisidha: In the residency and fellowship training curriculum, we do not have a special focus on sports imaging, but the trainees are exposed to a large number of musculoskeletal (MSK) injuries induced by sports. We have not established special courses for radiologists yet, but plan to do so in the near future.

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?

SJ: I work in a government-based teaching hospital. We teach medical students, also providing residency and fellowship training programmes. Sports-related imaging takes up a substantial part of my work since we provide service to MSK cases from all sections and departments, i.e. orthopaedics, rheumatology, rehabilitation, infectious diseases, paediatrics, etc.

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?

SJ: Football produces most injuries that require medical imaging. Lately, I have observed changes. For example, recent cases show more severe injury, involving multiple ligaments and structures, than those sent to magnetic resonance imaging (MRI) many years ago. This may be because since recently we have many more MR machines throughout the healthcare system, so the clinicians can request MRI earlier than in the past. That is why we can see injuries to many structures compared with the past, when the patients came to us when many structures had healed or were resolved. Cartilage injury provides the greatest challenge to radiologists and orthopaedic surgeons.

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

SJ: We are most familiar with sports injuries of the knee. It is the joint most frequently requested for imaging in our hospital. Usually, the imaging investigation starts with plain radiography, followed by MRI. For the shoulder joint, most cases are rotator cuff tear due to degenerative process in the elderly. Imaging investigation usually starts with plain radiography followed by MRI, similar to the knee. The shoulder dislocation cases are from both sports and accidents. Imaging investigation starts with plain radiography and then MR study. MR arthrography is frequently requested in this group of patients instead of routine MRI. We perform MR arthrography by using ultrasound guidance to avoid radiation to the youngest patients, who are typically young people. In addition, our pregnant staff can work with ultrasound. Sports injury to other joints is not that common, probably due to the types of sports performed in our country. Baseball, for example, is seldom played.

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

SJ: The diseases associated with sports activity that can be detected with imaging are patella-femoral abnormalities in the knee and rotator cuff tear in the shoulder.

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?

SJ: The role of the radiologist within this team is to provide diagnosis and differential diagnoses in all imaging modalities that are used, and to act as a consultant for cases in which one must decide what imaging modality is suitable. The cooperation between radiologists, surgeons, and other physicians unfolds in two steps. The diagnosis that we provide will help select the most appropriate treatment, and the other physicians, in particular the orthopaedic surgeons, will validate our interpretation whether it is correct or not. This will improve our accuracy and help treat patients more effectively.

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

SJ: In treatment and follow-up, the radiologists’ major role is to detect complications after treatment or when the patients do not show proper improvement within a sufficient period of time, particularly when physical examination is equivocal.

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?

SJ: Imaging can detect risk factors of sports injuries, i.e. a plain radiograph can detect narrow femoral notch in the knee, which is a risk factor for anterior cruciate ligament injury. But although we have this information beforehand, we cannot prevent injury. Certain information provided by medical imaging may be used to enhance the performance of athletes. For example, the study of muscles, both by MRI and MR spectroscopy (phosphorus study) may help determine muscle status and improve it through nutrition and exercise training.

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?

SJ: In Thailand, one hospital was certified by FIFA seven years ago, becoming one of five Asian institutions certified by the organisation. I had a role in setting up MRI for sports cases in this hospital three years before it was certified. I had worked there as part-time personnel for one year, making sure that everything went well and I resigned after that. I exposed many sports cases, and many of them were from the national football team. The knowledge I acquired in this setting is useful for injured patients beyond sports.

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?

SJ: The demand also increased in sports medicine due to increased sports performance, resulting in more injuries. Actually, we have guidelines for MRI requests, to make the most of available resources. The problem is we cannot completely stick to these guidelines. Knowledge in this regard is easily found on social media and patients frequently ask for imaging investigation, although their case does not fit the guidelines. The increase in lawsuits is another reason to break the guidelines. Many physicians have to request MRI to prevent the consequences.

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?

SJ: Athletes are exposed to small doses of radiation in plain radiography. The main modality is MRI, which does not use ionising radiation. Computed tomography (CT) is sometimes performed to identify small fractures or evaluate the healing process in areas difficult to assess with x-ray. We limit the radiation dose by performing only plain CT scans without contrast media and switching to plain radiography whenever possible.

European Society of Radiology: Sports imaging also applies to sports-related injuries of the brain. In case you are familiar with this, please also answer the following questions:

ESR: Which sports have the highest risk of inducing brain injuries?

SJ: We seldom have experiences with sports inducing brain injuries. According to our neuroimaging colleagues, boxing and football have the highest frequency.

ESR: What imaging modalities do you use with traumatic brain injury specifically in athletes?

SJ: No specific modality is used. For general trauma cases, we start with a non-contrast CT scan. If there is no abnormality on CT, but the patients still have signs and symptoms, we will proceed to MRI.

ESR: What can be learned from sports-related injuries that can be applied to a broader use, for example, those sustained through automobile or other accidents that cause traumatic brain injury?

SJ: We are not sure of the answer. In cases of suspected traumatic brain injury of any cause, we usually start with the same modality – a non-contrast CT scan of the brain.

ESR: How have advances in brain imaging allowed you to predict patient outcomes more accurately?

SJ: We usually perform this protocol in traumatic brain injury of any cause:

• Routine MR imaging of the brain: the more extensive haemorrhage, the poorer the outcome
• Diffusion-weighted imaging (DWI) to look for restricted diffusion found in cases with cytotoxic oedema from axonal injury, resulting in poorer outcome than vasogenic oedema

We have software and protocols believed to be of benefit in cases of traumatic brain injury, but currently not performed in such cases:

• MR spectroscopy (MRS):

Decreased NAA, NAA/Creatine ratio result in poorer outcome

• Diffusion Tensor Imaging (DTI):

Decreased fraction anisotropy (FA) related to poor neuropsychological performance

• MR perfusion (MRP):

Usually performed in tumour cases, to evaluate tumour blood supply

• Functional MRI (fMRI):

Persistent worsening of default mode network related with poor executive function