Under the magnet: Sports imaging emerges
“Musculoskeletal radiology didn’t really exist as a subspecialty until the mid-1970s…and within that sports medicine is only a small part of what we do,” explained Clyde A. Helms, MD, chief of musculoskeletal radiology at Duke University Health System in Durham, N.C. Helms completed a fellowship in musculoskeletal radiology in 1977 at the University of California, San Francisco (UCSF), the hospital’s first musculoskeletal fellow and only a handful of such trainees in the country at the time.
Today there are about 35 to 40 musculoskeletal fellowship programs in the U.S., Helms said, with Duke’s being one of the nation’s two largest. Consistently one of the top National College Athletic Association basketball colleges in the country, Duke’s Division 1 teams keeps university physicians busy and on the frontlines of academic research.
Duke’s basketball and football pull in the most special attention, because of their degree of impact and levels of play. “During football season we’ll reserve three or four spots on the MR unit on Monday, or even come in on Sunday after the Saturday game. This is common at most universities,” Helms said.
Unlike the ubiquitous boom in CT, MR is by far the dominant modality for sports injuries. “MR is the preferred way to look at most sports injuries because you can see so much more than plain films or CT, all the soft tissue and anomalies. It’s the more expensive modality, but it gives you a much more complete and comprehensive view of what you’re looking at.”
The elite athletes receive much more aggressive imaging not as a result of favoritism but because their diagnoses need to be made quicker than the average injury. Whereas conservative care, such as waiting a week or two for a film might be sensible for many uncertain injuries, “if a player injures his knee, ankle or shoulder, and they rest it for two weeks, before you know it their season is over. And for the professionals the cases are even more time-sensitive,” Helms insisted.
Helms estimated that knee studies make up roughly 35 percent of the sports cases he sees, with shoulder injuries accounting for a slightly lower percentage. Other common injuries are to the spine, ankle, wrist and hip.
One discrepancy where Duke and some other universities tend to provide players with better care than their professional role models receive is in pre-season screening. All players on the Duke basketball team undergo MRI prior to the start of each season.
The images enable Helms and his colleagues to track the team’s injuries over the season. This helps radiologists determine when pain only points to pre-existing injuries, which are more likely to heal quickly and without treatment, and when the images indicate new injuries that might require intervention. The screening has frequently provided radiologists important information, without which they would have recommended surgery, but could instead offer behavior modifications or less severe procedures.
“It’s amazing how much pathology you can see in athletes that they’re not even complaining about, such as tendonitis, contusions, jumper’s knee, all commonly found in a patient with a potential medial meniscus tear.” The role of these ancillary findings in promoting more conservative treatment in sports medicine figures interestingly into growing scrutiny over how physicians should manage ancillary findings.
Duke has looked into providing pre-season screening to professional teams, who have been reluctant to pick up the service. “It’s been really effective for us. I’m a little surprised when you’re paying multimillion dollar athletes that management wouldn’t want them to get screened. If I were paying an elite basketball player $20 million, I’d want to know everything about him,” Helms argued.
The role of radiologists in sports medicine imaging has grown tremendously in volume and influence. Whereas orthopedists could previously read plain films, “and often they’re better at it than radiologists,” Helms indicated that the spike in advanced imaging has shifted the dynamic of how athletes are diagnosed and managed.
And yet, sports imaging has experienced relatively little innovation in recent years. The main technological development has likely been introduction of 3T MRI, which provides higher quality images in less time than 1.5T MRI.
“But to be honest, other than speed and prettier pictures, I’m not sure there’s an advantage for routine knee, ankle, or shoulder MR,” Helms said. He also pointed to greater noise from breathing, motion, air, metal and other artifacts, as well as significantly higher costs of 3T MRs.
The prime advances to sports medicine have been interdisciplinary. With improvements in arthroscopy and surgery, surgeons have much more precisely identified what they look for in treating athletes, which has helped bridge the roles played by radiologists and surgeons in guiding one another for improved diagnosis and treatment of athletes.