The Clinician’s Point of View 1

The Clinician’s Point of View

3

B. M. Pluim, MD, PhD

KNLTB, PO Box 1617, 3800 BP Amersfoort, The Netherlands C O N T E N T S

1.1 Introduction 3 1.2 Role of Imaging 3

1.3 What is Expected from the Radiologist? 4 1.4 What is Expected from the Radiology Department? 4

1.5 What is Expected from the Sports Physician? 4

1.6 Risks of Over-Imaging 5 1.7 The Travelling Athlete 5 1.8 Conclusions 6

Things to Remember 6 References 6

The Clinician’s Point of View 1

Babette M. Pluim

1.1

Introduction

Over the last ten, years imaging techniques have become increasingly important as a diagnostic tool for sports injuries without replacing the traditional methods of management (Geertsma and Maas 2002; De March et al. 2005). An accurate diagnosis can often be made based on a history and physical examination alone but imaging techniques can be very helpful if there is doubt about the diagnosis. In patients who do not respond to conservative manage- ment, imaging can be especially useful to acquire a

better understanding of the extent of the lesion. How- ever, over-imaging can cause problems in high-level athletes, who have easy access to imaging modalities when travelling abroad. This is particularly so when there is lack of communication between the vari- ous treating physicians and when an understanding of the mechanism of injury is essential in order to establish the correct diagnosis.

This chapter will review a number of situations where good communication between the radiologist and sports physician can result in the correct choice of imaging technique and a greater chance of estab- lishing the correct diagnosis. The specifi c demands that elite athletes and sports physicians may place on the radiologist and the radiology department are also discussed.

1.2

Role of Imaging

It should be noted that the patient population of the sports physician differs slightly from the normal population. In general, athletes tend to be highly motivated and are keen to resume sport as soon as possible. The majority of their injuries are caused by training overload yet they fi nd it very diffi cult to reduce this load. There is always another match, another race, another goal to achieve. So in a situa- tion where a ‘normal’ patient may be content to give his/her ankle sprain or stress fracture the required three to six weeks rest, an athlete will want to know if he/she can participate in next week’s tournament.

When working with athletes, time is always a pres- sure.

This is where imaging can play an important role

for both the sports physician and the athlete. First,

by establishing the correct diagnosis at the start, the

correct treatment procedures can be initiated imme-

diately with no unnecessary time lag. Second, it is

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often very helpful to provide the athlete with visual evidence that a signifi cant injury is present (e.g.

stress fracture, muscle rupture or meniscal lesion) and thereby to convince him/her that rest is indeed essential. Hopefully this will also obviate the inclina- tion of the athlete to get multiple opinions (“medical shopping”). Finally, it may clarify whether surgery is necessary. In cases where conservative management is indicated, imaging may also help determine the appropriate form of treatment; for example, if calci- fi cations are present, use of Dolorclast (shock wave therapy) may be indicated. Despite the fact that cor- ticosteroid injections are used less and less in sports medicine, there are still instances when this type of treatment is indicated and imaging can help in this choice, e.g. a tenosynovitis (trigger fi nger), ganglion cyst, bursitis or iliotibial tract syndrome. Ultrasound may also be used to guide the injection needle (Jacob et al. 2005).

1.3

What is Expected from the Radiologist?

When dealing with elite athletes, there are certain aspects that differentiate the general radiologist from the ‘sports’ radiologist.

1. Interest in sports and ‘feel’ for the athlete. It is very important that the radiologist has an interest in sports and is able to place himself/herself in the position of the athlete. For athletes, minor injuries can cause great distress and hamper the athlete in his or her training (e.g. a minor muscle strain in a long-distance runner). The radiologist has to be aware of this fact and needs to look for minor abnormalities that may have no clinical signifi - cance in a non-athletic patient. It is essential that the radiologist is willing to analyze the problem with the sports physician.

2. Interest in the musculoskeletal system. The radi- ologist needs to be knowledgeable about the mus- culoskeletal system, because this is where the vast majority of sporting injuries occur. Musculoskel- etal imaging is still a developing fi eld in radiology (De March et al. 2005).

3. Access to a broad network. The radiologist does not need to be an expert in every area but should have a broad network of specialist colleagues who have an interest in and/or knowledge of sports related problems.

1.4

What is Expected from the Radiology Department?

1. Expertise in ultrasound imaging. The department should have a radiologist with extensive experience in ultrasound imaging and a specifi c interest in the musculoskeletal system. The radiology depart- ment should have Magnetic Resonance Imaging (MRI), CT-scan and bone scanning (DEXA) facili- ties in addition to plain radiography. If all these modalities are not available on site, the radiolo- gist should have alternative facilities to which the athlete can be referred.

2. Availability within 24 h to 5 days. Since there is a lot of time pressure on elite athletes, fl exibility and easy access is important. It is preferable that the department has slots open for elite athletes for diagnostics within 24 h to 5 days, if required. This is not always necessary, but can be essential when the athlete is competing in a tournament, or has to travel again within a short period of time.

1.5

What is Expected from the Sports Physician?

1. To provide detailed information. The sports phy- sician has to provide detailed information to the radiologist. For example, when referring an ath- lete with a high probability of a stress fracture, information regarding the nature of the activity or sport (e.g. jumping, hurdling, plyometrics) and the load on the athlete is very important in estab- lishing the diagnosis. A detailed history, including a training history, is essential. Most radiologists should have a high level of suspicion of a fracture of the 2nd metatarsal in military recruits or ath- letes. However, in order to detect more uncommon stress fractures (such as a humeral stress fracture in a tennis player, a stress fracture of the lower back in a gymnast, or a stress fracture of the hip in a long distance runner), good communication between the sports physician and radiologist is essential. This is particularly important because the sensitivity of plain radiographs in the early stages of a stress fracture is very low (Kiuru et al.

2004). In athletes where there is a high probability

The Clinician’s Point of View

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of a stress fracture, a normal radiograph should prompt further investigation with other imaging techniques (Tuan et al. 2004).

2. Seek advice before referring. Since the choice of the imaging modality depends on the expected type of lesion, the sports physician should be willing to seek advice from the radiologist before referring an athlete. No clearer example can be given than that the ideal imaging technique for examination of the shoulder joint (plain radiography, ultra- sound, MR(-arthrography) or CT(-arthrography), bone scan) will differ along with the clinical prob- lem (SLAP lesion, (partial) tendon rupture, bur- sitis, synovitis or fracture) (Sander and Miller 2005; Tirman et al. 2004).

1.6

Risks of Over-Imaging

When working with high level athletes, there are certain situations that are less likely to occur in the general population or in lower level athletes.

1. No direct relation between clinical symptoms and imaging fi ndings. Athletes are often tempted to repeat imaging to establish if “things are improv- ing”. The diagnosis is already established and imaging has already been carried out so repeat studies should only be undertaken if symptomatic improvement is not taking place. Repeat studies often lead to confusion in the mind of the ath- lete and coach. He feels better, he is getting better, but that is not confi rmed by MRI, which may cause anxiety. Not performing an imaging study would have been a better decision for the patient, although the hospital fi nance department might not agree. If the diagnosis is already known, and the treatment plan has been determined, and per- forming an imaging study will have no infl uence on this, imaging is unnecessary.

2. Non-signifi cant abnormalities. Asymptomatic athletes may have abnormalities on plain radio- graphs, CT-scan or MRI which have no clinical signifi cance. It is important to make this very clear to athletes in order not to disturb their positive body image.

3. Different reports. There is also the risk that serial imaging will produce slightly different reports.

Again, this may have no clinical signifi cance, but it is important to explain this clearly to the athlete

and his coach. Ultrasound or MRI reports are not always black and white, so if the reporting radi- ologist focuses on slightly different areas than the previous radiologist, this may lead to a confused athlete. For example, when examining a shoulder with ultrasound, there may be a thickening of the supraspinatus tendon, some fl uid in the bursa, and small calcifi cations present. If the (non-sig- nifi cant) calcifi cations were not mentioned the fi rst time, this may put doubt in the athlete’s mind that the injury is getting worse instead of better.

The same may happen with an MRI of the lower back after a herniated disc. Clinical symptoms do not always coincide with MRI images, and one clinician may call the herniation “small” whereas the next report may mention a “signifi cant” her- niation. It is always recommended that copies of the previous fi lms and reports are available when repeat imaging is being carried out.

1.7

The Travelling Athlete

An extra challenge may be encountered when deal- ing with elite athletes who are travelling regularly or have just returned from travelling. Their docu- mentation may be incomplete and the athlete may not know or remember whether they had a partial medial or lateral meniscectomy. Even the referring sports physician may not know the answer and this can make it very diffi cult for the radiologist who has to perform an MRI because of residual or recurrent symptoms. This problem has been recognised at the international level, but has not yet led to a unifi ed approach. Three options are available to tackle this problem:

1. The athlete carries his/her own ‘medical pass- port’ and takes it with him/her when they visit a doctor. This requires the athlete to be effi cient and carry the passport at all times. The feasibility of a

“hematologic passport” for endurance athletes has already been studied (Malcovati et al. 2003).

2. The injuries are registered in an electronic data-

base that is hosted by the international federa-

tion of the athlete’s sport. The governing bodies

in tennis (Association of Tennis Professionals,

Women’s Tennis Association and the International

Tennis Federation) are currently looking into the

possibilities of having a joint web-based database

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for all international players. The data need to be stored in a highly secure environment, whereby access is carefully controlled to ensure that data is available to relevant parties only. For example, tournament physicians will only have access to the data on players at their tournament during the tournament week. The principle of the system will be comparable to the Anti-Doping Admini- stration & Management System (ADAMS) that is currently in use by the World Anti-Doping Agency (WADA-AMA Org 2005).

3. The information is sent from the previous doctor to the current doctor by internet or by fax. This requires that the name of the previous doctor and hospital are known, that they can be traced, and that they are able to send this information very quickly. However, not all hospitals have a good electronic database that is able to store radio- graphs, MR images and other images in a reduced format.

1.8

Conclusions

The use of imaging techniques is an important tool for the sports physician in establishing the correct diagnosis and choosing the appropriate treatment procedures. In addition, imaging techniques can be useful for the evaluation and monitoring of the heal- ing process and the early identifi cation of complica- tions.

Good communication between the radiologist and the sports physician is essential. The information the sports physician provides to the radiologist regard- ing the history of injury, athlete’s training program and physical examination will help the radiologist choose the correct imaging technique. The sports physician should also share his/her knowledge of the special demands of the sport involved and the effects that this has on the musculoskeletal system of the athlete.

The radiologist should have an interest in sport and be willing to spend some extra time with the athlete for a detailed history and to communicate with the referring sports physician. The department should be fl exible enough to examine athlete within 24 h to 5 days, if warranted. Detailed feedback from the radi- ologist to the sports physician will help the latter to make the correct interpretation of any abnormalities

and direct him/her towards the appropriate form of treatment.

It is only as a result of teamwork between the sports physician and the radiologist that an optimal outcome can be achieved.

Things to Remember

1. The radiologist should have an interest in sport and be willing to spend some extra time with the athlete for a detailed history and to communicate with the referring sports physi- cian.

2. The use of imaging techniques is an impor- tant tool for the sports physician in establish- ing the correct diagnosis and choosing the appropriate treatment procedures. It is only as a result of teamwork between the sports physician and the radiologist that an optimal outcome can be achieved.

References

De March A, Robba T, Ferrarese E et al. (2005) Imaging in musculoskeletal injuries: state of the art. Radiol Med 110:15–131

Geertsma T, Maas M (2002) Beeldvormende diagnostiek in de sportgeneeskunde. Geneesk Sport 35:12–16

Jacob D, Cyteval C, Moinard M (2005) Interventional sonograhy.

J Radiol 86:1911–1923

Kiuru MJ, Pihlajamaki HK, Ahovuo JA (2004) Bone stress inju- ries. Acta Radiol 45:317–326

Malcovati L, Pascutto C, Cazzola M (2003) Hematologic pass- port for athletes competing in endurance sports: a feasibil- ity study. Haematologica 88:570–581

Sander TG, Miller MD (2005) A systematic approach to mag- netic resonance imaging interpretation of sports medicine injuries of the shoulder. Am J Sports Med 33:1088–1105 Tirman PF, Smith ED, Stoller DW et al. (2004) Shoulder imag-

ing in athletes. Semin Musculoskelet Radiol 8:29–40 Tuan K, Wu S, Sennett B (2004) Stress fractures in athletes:

risk factors, diagnosis, and management. Orthopedics 27:583–591

WADA-AMA Org. (2005) http://www.wada-ama.org/en/

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