Spy glass: radiological imaging to optimize clinical injury management – Part I

Dallas Mavericks guard A.J. Lawson lays on the ground due to an injury during the fourth quarter against the Denver Nuggets at Ball Arena. Mandatory Credit: Ron Chenoy-USA TODAY Sports

An average of 8.6 million people annually sustain an injury from physical activity in the USA. While sports and exercise activities are crucial for healthy lifestyles, they are also a large contributor to injuries to the population and a cause of sedentary periods⁽¹⁾. A significant number of these injuries, up to 50%, are attended to in various outpatient and primary healthcare facilities, such as General Practitioners’ and Physiotherapists’ rooms. These first-contact healthcare workers might refer the injuries for further investigations, the nature of which can vary. Usually, the first referral is for medical imaging. As technology is expanding, Radiology plays a larger role in diagnosing and managing sports injuries. Optimal outcomes for general wellness and return to sports depend on imaging and diagnoses to assist in management⁽²⁾.

Therefore, clinicians involved in managing sports injuries are responsible for familiarizing themselves with all imaging options and the effective use to manage their athletes correctly. A range of imaging options is available, and each modality’s role differs depending on the setting. Clinicians should familiarize themselves with the general rules for imaging⁽³⁾. A specific anatomical diagnosis is not always required for athlete management, and they should keep that in mind when referring an athlete for further investigations. In general, they should refer an athlete for imaging using the following guidelines:

• If it will influence injury management,
• When clinical diagnosis is uncertain, management may be affected by a differential diagnoses,
• To exclude serious abnormality in the presence of red flags,
• When injury or complications are unclear,
• Treatment has failed, and the reasons for this are unclear,
• To document the injury progression and recovery,
• Pre-operative localization and planning.

When referring an athlete for imaging, it is extremely useful to accurately describe the indication for the investigation with the working diagnosis on the image request form. This allows the imaging team to optimize the approach by following the specific questions for the radiologist to answer. This helps to direct the search pattern and analysis, leading to improved reporting. The rationale for different imaging options will vary with the following⁽⁴⁾: 

• Clinical diagnosis and differentials,
• Local availability of options and expertise of the imaging team,
• Athlete considerations: cost, convenience, and compliance,
• Safety considerations: age, radiation dose, and contrast sensitivity.

Clinicians must understand the different available imaging options to ensure an accurate diagnosis. Delayed diagnosis frustrates athletes and may be associated with increased costs, placing an extra burden on strained healthcare resources and creating psychological stress from misrepresenting morphological rather than pathological findings. The imaging options typically available in sports include X-ray, ultrasound (US), magnetic resonance imaging (MRI), and computed tomography (CT) (see table 1). 

X-rays play a significant part in diagnosing and managing sports injuries, primarily because of their wider availability. Typically, clinicians use them to rule out significant skeletal injury, and failure to have X-rays before MRI and US can lead to errors in imaging. Ultrasounds are useful for investigating superficial structures and soft tissues, especially tendons and bursae. It can also be used for pathodynamic imaging, dynamic muscle assessment, to guide therapeutic interventional procedures such as injections, and to monitor healing progress⁽⁴⁾.

If an X-ray or US scan is not indicated, clinicians may opt for more in-depth investigations such as MRI and CT. Importantly, the request for these two investigations should be done after a comprehensive subjective and objective assessment. Furthermore, clinicians should educate athletes on the indications, pros, and cons. Magnetic resonance imaging is ideal for a detailed investigation of the musculoskeletal system. Typically, an MRI is ordered when there is an unclear diagnosis after an X-ray or US. An MRI is non-invasive and provides an objective means of long-term post-operative monitoring. One major benefit is its excellent negative predictive value, allowing practitioners to proceed with manual therapy or another conservative intervention more confidently.

Compared to MRI, CT has easier access and shorter examination time, and it can be used for sporting injuries involving bones. Computed tomography scans in sports environments are less common than X-rays, US, and MRIs. Still, clinicians may order CT scans in the following cases:

1. The assessment of bone cortical and trabecular architecture,
2. The assessment of fracture lines, small calcifications, loose bodies, bone erosions, and mineral loss or destruction,
3. Pre-operative 3D modeling of complex bony fractures,
4. Suspected bony injury, where X-ray findings are equivocal,
5. Bone or large soft-tissue injuries, where MRI is not available or contraindicated.