Sport-Speciﬁ c Injuries 30

(1)

Sport-Speciﬁ c Injuries

505

O. Papakonstantinou,

Lecturer of Radiology, 2nd Radiology Department, University of Athens, Rimini 1, 12462, Athens, Greece

A. D. Kelekis, MD, PhD

Lecturer of Interventional and Musculoskeletal Radiology, 2nd Radiology Department, University of Athens, Rimini 1, 12462, Athens, Greece

N. L. Kelekis, MD, PhD

Associate Professor of Radiology, 2nd Radiology Department, University of Athens, Rimini 1, 12462, Athens, Greece D. A. Kelekis, MD, PhD

Professor of Radiology, Research Department of Imaging and Interventional Radiology, University of Athens, Eugenidion Hospital, Papadiamantopoulou 20, 11528, Athens, Greece

Sport-Speciﬁ c Injuries 30

Olympia Papakonstantinou, Alexis D. Kelekis, Nikolaos L . Kelekis, and Dimitrios A. Kelekis

C O N T E N T S

30.1 Introduction 505 30.2 Stress Fractures 506 30.3 Muscle Injuries 507

30.4 Spondylolysis and Other Sports Related Lesions of the Spine 510

30.5 Knee Injuries 510 30.6 Ankle Injuries 513 30.7 Shoulder Injuries 514 30.8 Conclusion 517

Things to Remember 517 References 517

ologists and technologists from all over the country were recruited whereas Hellenic Armed Forces pro- vided additional medical and paramedical personnel in order to insure access to all imaging facilities for athletes residing in the Olympic Village on a 24 h basis. The equipment of the Radiology Department comprised standard radiography (including digital ﬂ uoroscopy), ultrasound, multidetector CT and MR imaging. Additionally, Picture Archiving and Com- munication System was available. From 29

^th

of July to 30

^th

of August 2004, approximately 1500 imaging studies were performed in the Olympic Polyclinic, involving approximately 800 athletes, providing a wide spectrum of injuries suffered by elite athletes in a wide variety of sporting activities. The majority of the requests for imaging concerned suspicion of stress fractures, muscle injuries, knee and ankle inju- ries in athletes during competition or training. The 2004 Olympic records, deriving from the archives of Olympic Polyclinic, were reviewed for sports related injuries by competing athletes, and are summarized in Table 30.1.

Some additional comments on the most frequent injuries will be provided in the next paragraphs.

Most frequent musculoskeletal injuries based on the experience during the Summer Olympic Games 2004

30.1 Introduction

The purpose of this chapter is to give an overview of

the relative frequency of musculoskeletal sports inju-

ries, documented by imaging studies in a population

of elite athletes. The information within this chapter

is derived from our experience during the summer

Olympic Games, held in Athens 2004. The games

brought together approximately 11,000 athletes from

all over the world. Medical care to athletes, members

of national missions and workforce was provided at

a multidisciplinary clinic, the Polyclinic, which was

located in the Olympic Village. Polyclinic Services

were linked to the Greek National System Health

Service System, which provided free access to emer-

gency services offered by dedicated Olympic Hospi-

tals. The Radiology Department of the Polyclinic was

installed and mostly staffed by the 2

^nd

Department of

Radiology of the University of Athens. Volunteer radi-

(2)

30.2 Stress Fractures

Stress fractures and stress reactions accounted for more than 10% of injuries. Stress fractures were located most commonly at the anterior tibial sur- face. Stress fractures of the navicular bone, meta- tarsals, malleoli, calcaneum, ischium, carpal bones and pars interarticularis of lumbar vertebrae were also recorded. Sport activities that most commonly caused stress fractures or reactions were running for superior tibia and femur, gymnastics for anterior tibia and ischium, team sports requiring jumping and run- ning such as basketball and handball for metatarsals and navicular bone and, ﬁ nally, weight-lifting and diving for lumbar vertebrae. Patients presented with pain that was relieved with rest and restarted after activity, whereas in more severe injuries the patients suffered even in rest.

Standard radiographs were quite sensitive for vis- ualization of cortical stress fractures in tibia. Cortical stress fractures were typically seen in gymnasts, at the anterior aspect of the tibia. Occasionally, multiple and bilateral stress fractures were seen (Fig. 30.1).

The most frequent stress fracture of cancellous bone involved the navicular bone, seen in four ath- letes (two basketball, one handball player and one long jumper).

In contradistinction to cortical stress fractures, these fractures could not be visualized on radiographs and may be missed as they may present with non speciﬁ c signs and insidious onset. In these cases, additional CT or MRI was required for the diagnosis (Figs. 30.2 and 30.3). Navicular stress fractures could be demon-

Table 30.1. Most common injuries in Olympics 2004

Fractures, stress fractures and stress reactions Muscle strains

Ligamentous and meniscal injuries of the knee Achilles tendinosis

Plantar fasciitis

Tears of plantar fascia and plantar plate

Injuries to lateral ligamentous complex of the ankle Rotator cuff tendinosis and tears

Labral tears in shoulder

Disk hernia and spondylolysis of the lumbar spine

Fig. 30.1. Multiple cortical stress fractures of the tibia in a 25-year-old female gymnast with chronic bilateral lower leg pain. Lateral radiograph of the left leg demonstrates horizon- tal lucent lines in the cortex of anterior tibia (arrows), with adjacent cortical sclerosis

Fig. 30.2. Non-united stress fracture of the navicular bone in a 33-year-old basketball player presenting with non-speciﬁ c ankle pain. A coronal STIR image shows a linear area of high signal at the fracture site with surrounding bone marrow edema. The fracture has a typical sagittal orientation

(3)

507 strated on coronal and axial MR images as complete or incomplete fractures in the medial third of the bone (Fig. 30.2), which is considered to be relative avascular and more prone to the shearing forces oriented in the sagittal plane (Ting et al. 1988; Vanhoenacker et al.

2004). Multidetector CT, however, was more accurate to demonstrate the precise extent of the fracture line, due to due to its multiplanar reconstruction capabili- ties in the sagittal and coronal plane (Fig. 30.3).

MR imaging could additionally reveal early osseous stress injuries and thus modiﬁ ed training of the athletes (Arendt and Grifﬁ th 1997).

Stress injuries were categorized according to the classiﬁ cation proposed by Fredericson et al. (1995) into four grades, which are discussed in more detail in Chap. 7. Stress reactions grades 2 and 3 were more frequently seen than complete stress fractures.

30.3 Muscle Injuries

Muscle injury was the most common indication for ultrasound and the third most common indication for MR imaging (after knee and ankle injury). Muscle

injuries have been categorized in muscle strains, con- tusions and avulsions (Nguyen et al. 2000; Boutin et al. 2003; De Smet et al. 1993). Muscle strains were the most frequent muscle injuries (n=28), whereas muscle contusions (n=2) and avulsions (n=2) were rare. Muscle strains occurred more frequently in run- ners (n=15), followed by volleyball and tennis players (n=7), in whom a powerful muscle contraction was combined with simultaneous forced lengthening of the myotendinous unit (De Smet et al. 1993), and involved more frequently muscles that crossed two joints such as rectus femoris (n=5), gastrocnemius (n=6) and hamstrings (n=21). Another mechanism of injury included eccentric contraction of muscle crossing one joint (Boutin and Newmann 2003), such as adductor muscles injuries (seen in two run- ners and four judo players) or pectoralis major injury in a weight-lifter.

Grading of muscle strains was done by using the grade 3 classiﬁ cation system (see Chap. 3). Approxi- mately 70% of muscle injuries comprised mild strains. US was more sensitive than MR in subtle muscle strains including muscle elongation and subtle perifascial edema (Figs. 30.4 and 30.5) whereas MR provided more accurate estimation of the extent of severe muscle injury (Figs. 30.6 and 30.7). Further- more, MR could reveal associated bone injury (if any)

Fig. 30.3a,b. Stress fracture at the capitate in a 33-year-old cyclist with wrist injury. Reformatted CT images in the coronal (a) and sagittal plane (b) revealing a stress fracture at the middle aspect of the capitate (arrow)

a b

(4)

Fig. 30.4a,b. Mild muscle injury in a 22-year-old elite tennis player who pre- sented with acute calf pain during competition. a Ultrasound of the right calf demonstrates subtle subfascial hyperechogenicity adjacent to the vastus late- ralis muscle. b On a transverse STIR MR image, a barely seen hyperintensity with indistinct margins is shown at the vastus lateralis muscle and adjacent subcutaneous fat

a

b

Fig. 30.5a,b. An axial STIR image shows a grade 1 strain of the left rectus femoris muscle in a 23 year-old hockey player. A feathery pattern is seen on MRI a), whereas a diffuse hypoechogenicity is seen on US b), without disruption of muscle ﬁ bers

a b

R L

(5)

509

Fig. 30.6a,b. Third degree strain in a 21-year-old judo player presenting with acute pain at the symphysis pubis. A coronal T2-weighted MR image shows complete rupture of the left adductor longus muscle with distal retraction (a). Corresponding longitudinal ultrasound image (b) of the same patient, demonstrates retraction of the proximal muscle belly and hypoechoic ﬂ uid extending along the fascia

a b

Fig. 30.7a,b. Rupture of the rectus femoris muscle in a 29-year-old runner who presented with a palpable mass at the anterior thigh. A sagittal STIR image (a) shows rupture of the rectus femoris muscle with distal retrac- tion of the tendon and hematoma extending along the proximal muscle belly (b)

b

a

(6)

that might be missed on clinical examination. Partial tears were shown as discrete round or stellate lesions with high signal on T2-weighted MR images and were characterized by partial disruption of muscle ﬁ bers, low grade, if less than one-third of muscle ﬁ bers was torn, and high grade if more than two- thirds were torn (Boutin et al. 2003). Some degree of laxity and attenuation of the tendon occasion- ally accompanied the muscle injury due to dimin- ished strength of the injured muscle (De Smet et al.

1993; Boutin and Newmann 2003). The signal of the hematomas is expected to modify in regard to the age of the hematoma; however the hematomas depicted in this study population were in the acute stage and, thus, disposed the signal intensities of ﬂ uid on T1- and T2-weighted images. Both in mild and moder- ate muscle injuries there were perifascial ﬂ uid and edema adjacent to the injured muscle. A severe injury of the rectus femoris muscle created a pseudotumor appearance (Temple at al. 1998) that was seen as an indiscrete, rather inhomogenous mass like lesion at the site of musculotendinous junction (Fig. 30.7). In that case, clinical examination usually reveals a pal- pable mass at the site of disruption of rectus femoris muscle. Of the six cases of complete muscle tear, seen in our series, three involved the adductor longus, one the rectus femoris and one the adductor gracilis.

Muscle contusions were rare and were caused by direct blunt trauma to muscles, as seen in the rectus abdominis muscle of a tennis player hit by the tennis ball. Hematoma formation in and around the muscle coexisted. Blunt trauma results in interstitial edema and hemorrhage, that is more extensive compared to

strains however the recovery is faster (Coulouris and Connell 2003).

Muscle avulsions were not common in our study population as they usually occur in skeletally imma- ture patients (see Chap. 26). One case of avulsion of the hamstring tendon from ischial tuberosity was recorded in a runner (Fig. 30.8) and another avulsion of the triceps tendon from the olecranon in a weight- lifter. The hamstring tendons are the most frequently injures tendons in jumping and running. In our series, the myotendinous junction or the muscle belly was the most frequent location of tendon injury, which is in line with the literature (Coulouris and Connell 2003). Indeed, avulsion of the hamstrings from their insertion site at the posterolateral ischial tuberosity is considered a rare acute injury.

30.4 Spondylolysis and Other Sports Related Lesions of the Spine

Stress fracture of the pars interarticularis is due to repetitive hyperextension of the spine putting stress on the posterior bony elements (Commandre et al.

1988). Initially, a stress reaction in the pars is incited that leads to real stress fracture (Rossi 1988). Such injuries were observed in two weight-lifters, one gym- nast and one diver (Fig. 30.9). All patients presented with low back pain that could be confused clinically with disk disease or strain of the back muscles. In our series, CT with axial and sagittal reformatted images was more sensitive in visualization of subtle corti- cal defects and in the follow-up of healing of stress fractures, whereas MR imaging was more sensitive for the initial diagnosis of stress reactions by demon- strating bone marrow edema (Gundry and Fritts 1999). Other lesions causing low back pain included disk bulging, protrusion or extrusion and decreased disk height. Annular tears were also not uncommon and aggravated low back pain.

30.5 Knee Injuries

MRI of the knee was the most frequently requested MR study which comprised 25% of requested MR

Fig. 30.8. Avulsion of the left hamstring tendons from the ischial tuberosity, in a 39-year-old long distance runner. Axial STIR image demonstrating edema and hemorrhage surrounding the avulsed fragment

(7)

511

Fig. 30.9a–c. Stress fractures at the pars interarticularis in a 25-year-old diver with low back pain.

CT revealed lucent fracture lines with adjacent sclerosis (a). The fractures are hypointense on axial T1-weighted MR images (b) as well on sagittal STIR images surrounded by hyperintense bone marrow edema (c)

b a

c

imaging studies. Meniscal tears and ligamentous injuries were found in 33 and 28 studies respectively.

The most common ligamentous injury was a com- plete tear of the anterior cruciate ligament (ACL) in 17 athletes, followed by a partial tear or sprain of the medial collateral ligament (MCL) in 13 and lateral collateral ligament (LCL) in 7 athletes, with concomitant popliteus injury in 3 of them. Complex ligamentous injuries, comprising injury of two liga- ments and accompanied by at least one meniscal tear, were found in ten athletes of volleyball, basketball and ﬁ ghting sports such as judo and tae-kwo-do.

Complex ligamentous injuries usually included an injury to anterior cruciate ligament (ACL), medial collateral ligament (MCL) along with tears of the medial or lateral meniscus or both, comprising an

‘unhappy triad” or “tetrad”, respectively. In fi ghting sports, simultaneous injuries to both the lateral and medial supporting structures were not uncommon, implying involvement of more than one mechanisms of injury and recurrent injuries. Numerous mecha- nisms of injury can be associated with ACL tears (Hayes et al. 2000; Sanders et al. 2000; Recondo et al. 2000), including a valgus and external rotation force or a varus and internal rotation force on a fi xed tibia in fi ghting sports, rapid change of direction or sudden contraction of the quadriceps tendon in basketball or handball. In all cases, there were con-

comitant bone bruises on the posterolateral tibial plateau and lateral femoral condyle, due to anterior translocation of the tibia and impaction between lat- eral posterior tibia and femur, whereas more subtle bone marrow edema was often seen at the postero- medial tibial plateau and at the femoral site of attach- ment of medial collateral ligament due to traction forces (Chan et al. 1999). Displaced meniscal tears were observed in 8 of 33 meniscal injuries and were in most cases associated with ligamentous injuries (Fig. 30.10). Rupture of the ACL graft was seen in three athletes (Fig. 30.11); in one of them there was anterior placement of the tibial or femoral tunnel (Papakonstantinou et al. 2000), whereas degenera- tive changes were uncommon in athletes with an old ACL injury. Avulsion fractures around the knee joint were rare. Only a subtle Segond avulsion fracture that accompanied ACL and lateral meniscus tear was seen in a judo athlete.

On the other hand, overuse injuries involving the

extensor mechanism were much more frequent in

jumpers and volley ball players. They included chon-

dromalacia patellae in six cases and a spectrum of

patellar overuse injury in seven athletes, ranging from

patellar tendinosis, demonstrated as signal increase

in the proximal end of patellar tendon (jumper’s

knee) (Khan et al. 1996) to severe cystic degenera-

tion (Fig. 30.12).

(8)

Fig. 30.10a–c. A 29-year-old female judo player with clini- cal suspicion of ACL tear and acute blocking of the knee. A sagittal proton density weighted MR image (a) displays acute tear of the ACL whereas on a adjacent sagittal proton density weighted MR image (b) the double PCL sign indicative of a bucket handle tear of the posterior horn of medial meniscus is seen. On a coronal T2* MR image (c) a partial tear of the LCL (arrow) is also seen along with absence of the posterior horn of medial meniscus

a b

c

Fig. 30.11. Recurrent injury in a 27-year-old handball player with an ACL graft from patellar tendon, although the tibial tunnel was appropriately positioned. A sagittal T2 weighted MR image shows complete disruption of an ACL graft at its femoral attachment, along with tearing of the posterior cap- sule (arrow)

(9)

513

30.6 Ankle Injuries

Injuries to the ankle joint and foot were the most common injuries during the Olympics. Radiographs of the foot and ankle were the most frequently requested imaging examination, whereas MRI of the ankle was the second most requested MR examina- tion. A variety of injuries involved the ankle joint the most frequent being overuse injuries to the Achil- les tendon (n=11), injuries to the anterior talofi bu- lar (n=9) including chronic tears with anterolateral impingement, syndesmotic sprain (n=4), plantar fas- ciitis (n=9) with tear of the plantar fascia (n=4) and fi nally osseous injuries including stress fractures or stress reactions of the navicular bone (n=5), meta- tarsals (n=3), fi bula (n=2) and calcaneum (n=1).

Osseous impingement (Miller et al. 1995) caused either by bony excrescences, osteophytes at the tal- onavicular joint or accessory ossicles, such as the os trigonum posteriorly or accessory navicular bone (Bernaerts et al. 2004) were not infrequent, occa- sionally leading to tendinopathy of adjacent tendons or bone and syndesmotic injury.

Achilles tendon was evaluated initially with US.

An additional MR examination was only performed if associated injuries to other structures were sus- pected and if a larger FOV was needed (Zoga and Schweitzer 2003). Interstitial tendinonis with par- tial tear and paratenonitis was frequent in athletes involved in jumping and running, whereas inser- tional tendinosis, with paratenonitis and retrocalca- neal bursitis was common in runners (Bencardino et al. 1999; Dunfee et al. 2002).

Lateral ankle sprains, associated with inversion and plantar ﬂ exion and occasionally axial loading, were seen in athletes of all sport categories, more fre- quently in basketball, soccer, handball and runners.

Chronic or acute injuries to the anterior taloﬁ bular ligament were common, leading to instability and osteochondral injuries at the posteromedial or the midlateral talar dome, whereas tibioﬁ bular syn- desmotic injuries were less frequent. Chronic inju- ries of the lateral ligamentous structures were seen as absence, attenuation or thickening and laxity of the ligaments (Fig. 30.13) and were usually associ- ated with scarring of the capsule, resulting in the so called meniscoid lesion (Robinson and White 2002;

Jordan et al. 2000). This hypointense lesion occupied the anterolateral gutter of the joint and provoked anterolateral impingement and chronic pain during dorsiﬂ exion of the foot.

Heel pain was a frequent clinical indication for ankle MRI and plantar fasciitis was the most common cause of heel pain, observed in nine patients. Although it is basically a clinical diagnosis, MR imaging was used to evaluate the extent of injury whereas radiographs were useful to exclude other causes of heel pain. MR imaging clearly depicted increased intrasubstance signal in acute plantar fasciitis, whereas thickening of the plantar fascia with perifascial edema indicated chronic fasciitis. A calcaneal spur at the insertion of the plantar fascia along with bone marrow edema of the calcaneum were frequent ancillary ﬁ ndings. Tears of plantar fascia were seen in two athletes, as partial or complete disruption of the fascia respectively.

Metatarsal stress fracture and/or plantar plate rupture causing metatarsalgia were seen in handball player (Fig. 30.14) and runners. The plantar plate is a fi brocartilagenous structure contiguous with the anterior and plantar aspect of the joint capsule of the metatarsophalangeal joints, providing resistance to dorsifl exion (Mohana-Borges et al. 2003; Umans and Elsinger 2001). Springing forward a plantar fl exed foot on a hard surface (handball) or in run- ners accelerating from the starting blocks (Zoga and

Fig. 30.12. A 25-year-old, male, volleyball player with anterior knee pain. A sagittal proton density weighted MR image shows extensive mucoid degeneration of patellar tendon (arrow), along with avulsion of the tibial tuberosity (arrowhead)

(10)

Fig. 30.13a–d. A 30-year-old female basketball player disposed exten- sive low signal in the lateral gutter that displays low signal on an axial T1-weighted MR image (a), and on an axial STIR image (b) (arrow). It extends anteriorly and posteriorly in (a). The anterior taloﬁ bular liga- ment is torn in (a). There is concomitant chronic injury of the anterior tibioﬁ bular ligament that is thickened (c) and an osteochondral injury at the midlateral talar dome (d)

b

d

a c

Schweitzer 2003), may generate dorsiﬂ exion forces at the metatarsophalangeal joints resulting in rupture of the plantar fascia or stress fracture of the metatar- sals or both.

Stress fractures or stress reactions, as described above, were not uncommon, and were seen in seven athletes (three basketball players, two jumpers and two gymnasts) (Fig. 30.2). Foci of bone marrow edema in multiple tarsal bones and malleoli without associated ligamentous injuries were occasionally seen in gymnasts and runners who presented with ankle pain (Schweitzer and White 1996). Gym- nasts were frequently very young and thus skeletally immature and subject to injuries of epiphyseal plates, which appeared widened and irregular (Fig. 30.15).

30.7 Shoulder Injuries

Shoulder injuries are typically associated with throw-

ing sports (Altcheck and Hobbs 2001; Sherbondy

and McFarland 2004); however in our study group

apart from throwing athletes, such as two javelin

throwers, injuries to the shoulder were recorded in

athletes involved in a variety of sports including

boxing, judo, handball, basketball, softball, swim-

ming, sailing, weightlifting and gymnastics. Lesions

suggesting rotator cuff impingement or instability

were found in 22 of the MR studies of the shoulder,

whereas both impingement and instability were diag-

(11)

515

Fig. 30.14a,b. A 25-year-old, male, handball player with forefoot pain. A short axis T2-weighted MR image shows rupture of the plantar plate with adjacent fl uid collec- tion, after acute dorsifl exion on a hard surface (a). A long axis STIR image reveals a barely visible stress fracture (arrow) at the base of the fi fth metatarsal (b)

a

b

Fig. 30.15a,b. Salter-Harris I injury in a 15-year-old female gymnast with chronic left ankle pain. STIR images (a) display increased marrow signal of the fi bula. Note widening of the epiphyseal plate of the distal fi bula (arrow in b). Note also strain of the fl exor hallucis longus muscle and scattered foci of bone marrow edema through the ankle joint in (a)

a b

nosed in 6 out of those 22 (28%). Superior labrum anterior to posterior lesions (SLAP) were visualized in 3/22 (14%); however the true incidence of the above mentioned lesions may be underestimated since MR arthrography which is the method of choice, was not performed due to constraints regarding the applica- tion of invasive procedures and contrast media.

In case of suspected or known isolated injury of the supraspinatus tendon, US was the ﬁ rst exami- nation performed. It was also used for follow up to evaluate the healing procedure (Fig. 30.16).

Imaging features of instability comprised injuries

to the anterior inferior capsulolabral complex includ-

ing injury to the inferior glenohumeral ligament

(12)

Fig. 30.16. Ultrasound examination of the rotator cuff, show- ing a chronic partial rupture of the supraspinatus tendon (arrow)

Fig. 30.17a–d. A 23-year-old male gymnast with right shoulder pain. There is an undersurface tear of the posterior part of the supraspinatus and the superior part of the infraspinatus tendons shown on coronal STIR images (a). An axial T2-GRE MR image shows a tear of the superior – posterior labrum and an impaction fracture at the posterolateral aspect of humeral head (b). A cyst on the insertion of cuff on the humeral head which also seen (arrow). A more cranial section (c) displays thickening and waviness of the rotator interval structures along with tear of superior labrum extending anteriorly to posteriorly (SLAP), whereas a more caudal section (d) shows injury to the inferior glenohumeral ligament (IGHL) which is avulsed from the humeral head and a Bankart lesion medially

a b

c d

(IGHL), detachment of the anterior inferior labrum with tear of the anterior periosteum (Bankart lesion) with associated compression fracture of the postero- lateral aspect of the humeral head (Hill-Sachs lesion) and in one athlete, additional avulsion of the IGHL from the humeral head (Fig. 30.17).

Posterosuperior internal impingement syndrome

was seen in three athletes involved in boxing, handball

and in one gymnast in whom there were concomitant

signs of instability (Fig. 30.17). Occult fractures of the

greater tuberosity were seen in two cases of contact

injuries in young athletes, due to an excessive tensile

strength of the cuff compared to the resistant forces

of bone (Zanetti et al. 1999).

(13)

517 30.8 Conclusion

During the Summer Olympics in 2004 the most fre- quent musculoskeletal injuries consisted of muscle strains, mainly of biceps femoris, gastrocnemius, adductors and rectus femoris, stress fractures (located mainly in the tibia, navicular bone and metatarsals) and knee injuries including isolated meniscal tears, ACL ruptures followed by more complex ligamentous injuries. Subtle muscle strains could be depicted by ultrasound whereas MRI was more accurate in iden- tifying the extent of a more severe injury. The most common injuries at the ankle joint were lateral liga- mentous injuries often combined with impingement, tendinosis of the Achilles tendon and plantar fasciitis, or tears, and stress fractures of the navicular bone and metatarsals. At the shoulder, rotator cuff tears and/or instability lesions were most frequent. Lower back complaints were frequent and stress injuries of the pars interarticularis were not uncommon.

References

Altchek DW, Hobbs WR (2001) Evaluation and management of shoulder instability in the elite overhead thrower. Orthop Clin N Am 3:423–430

Arendt EA, Grifﬁ ths HJ (1997) The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med 16:291–306

Bencardino J, Rosenberg ZS, Delfault E (1999) MR imaging in sports injuries of the foot and ankle. Magn Reson Imaging Clin N Am 7:131–148

Bernaerts A, Vanhoenacker FM, Van de Perre S et al. (2004) Accessory navicular bone: not such a normal variant. JBR- BTR 87:250–252

Boutin RD, Newmann JS (2003) MR imaging of sports-related hip disorders. Magn Reson Imaging Clin N Am 11:255–281 Boutin RD, Fritz RC, Steinbach LS (2003) Imaging of sports- related muscle injuries. Magn Reson Imaging Clin N Am 11:341–371

Chan KK, Resnick D, Goodwin D et al. (1999) Posteromedial tibial plateau injury including avulsion fracture of the semimembranous tendon insertion site: ancillary sign of anterior cruciate ligament tear at MR imaging. Radiology 211:754–758

Commandre FA, Taillan B, Gagnerie F et al. (1988) Spondy- lolysis and spondylolisthesis in young athletes: 28 cases. J Sports Med Phys Fitness 28:104–107

Coulouris G, Connell D (2003) Evaluation of hamstring muscle complex following acute injury. Skelet Radiol 32:582–589 De Smet AA, Fisher DR, Heiner JP et al. (1993) Magnetic

resonance ﬁ ndings in skeletal muscle tears. Skelet Radiol 22:479–484

Dunfee WR, Dalinka MK, Kneeland JB (2002) Imaging of athletic injuries to the ankle and foot. Radiol Clin N Am 40:289–312

Fredericson M, Bergman G, Hoffman KL et al. (1995) Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 23:472–481

Gundry CR, Fritts HM (1999) MR imaging of the spine in sport injuries. Magn Reson Imaging Clin N Am 7:85–103 Hayes CW, Brigido MKI, Jamadar DA et al. (2000) Mechanism-

based pattern approach to classiﬁ cation of complex injuries of the knee depicted at MR imaging. Radiographics 20:S121–S134

Jordan LK, Helms CA, Cooperman AE et al. (2000) Magnetic resonance imaging ﬁ ndings in anterolateral impingement of the ankle. Skelet Radiol 29:34–39

Khan KM, Bonar F, Desmond PM et al. (1996) Patellar tendinosis (jumpers knee): ﬁ ndings at histopathologic examination, US and MR imaging. Victorian Institute of Sport Tendon Study Group. Radiology 200:821–827

Miller TT, Staron RB, Feldman F et al. (1995) The symptomatic accessory tarsal navicular bone: assessment with MR imaging. Radiology 195:849–853

Mohana-Borges AV, Theumann NH, Pﬁ rmann CW et al. (2003) Lesser metatarsophalageal joints: standard MR imaging, MR arthrography, and MR bursography- initial results in 48 cadaveric joints. Radiology 227:175–182

Nguyen B, Brandser E, Rubin DA (2000) Pains, strains and fas- ciculations: lower extremity muscle disorders. Magn Reson Imaging Clin N Am 8:391–408

Things to Remember

1. Although ankle and foot lesions were the most frequent sports injuries, MR examination of the knee was the most frequent requested MR examination, followed by MRI of the ankle and foot.

2. Stress fractures/reactions comprise 10% of sports injuries.

3. Muscle injuries were the most frequent indi- cation for ultrasound.

4. Shoulder injuries were not exclusively seen in

throwing sports, but in a variety of athletes.

(14)

Papakonstantinou O, Chung C, Chanchairujira K et al. (2003) Complications of anterior cruciate ligament reconstruc- tion: MR imaging. Eur Radiol 13:1106–1117

Recondo JA, Salvador E, Villanua JA et al. (2000) Lateral sta- bilizing structures of the knee: functional anatomy and injuries assessed with MR imaging. Radiographics 20:

S91–S102

Robinson P, White LM (2002) Soft tissue and osseous impingement syndromes of the ankle: Role of imaging in diagnosis and management. Radiographics 22:1457–

1471

Rossi F (1998) Spondylolysis, spondylolisthesis and sports. J Sports Med Phys Fitness 18:317–340

Sanders TG, Medynski MA, Feller JF et al. (2000) Bone contu- sion patterns of the knee at MR imaging: footprint of the mechanism of injury. Radiographics 20:S135–151

Schweitzer ME, White LM (1996) Does altered biomechanics cause marrow edema? Radiology 198:851–853

Sherbondy PS, McFarland EG (2004) Shoulder instability in the athlete. Phys Med Rehabil Clin N Am 4:729–743

Temple HT, Kuklo TR, Sweet DE et al. (1998) Rectus femoris muscle tear appearing as a pseudotumor. Am J Sports Med 26:544–548

Ting AM, King W, Yocum L et al. (1988) Stress fractures of the tarsal navicular in long distance runners. Clin Sports Med 7:89–101

Umans HR, Elsinger E (2001) The plantar plate of the lesser metatarsophalangeal joints: potential of injury and role of MR imaging. Magn Reson Imaging Clin N Am 9:659–669 Vanhoenacker FM, Van de Perre S, De Praeter G et al. (2004)

Proceedings of the SRBR-KBVR Osteoarticular section meeting of October 18, 2003 in Antwerp – part two: imaging of foot anomalies. JBR-BTR 87:305–309

Zanetti M, Weishaupt D, Jost B et al. (1999) MR imaging for traumatic tears of the rotator cuff: high prevalence of greater tuberosity fractures and subscapularis tendon tears. Am J Roentgenol 172:463–467

Zoga AC, Schweitzer ME (2003) Imaging of sports injuries of the foot and ankle. Magn Reson Imaging Clin N Am 11:295–310