Imaging in Sports Injury

1. By Dr. Rajal Sukhiyaji

2. CONTENTS
Introduction
Role of imaging
Risks of over imaging
The travelling athlete
Imaging Modalities
Safety, Availability and economic
aspects
References

4.  Imaging in Medical field
 Importance of imaging technique
 Doubt about the Diagnosis
 Accurate assessment of injury
 Helpful to provide the athlete with visual
evidence that a significant injury is present
 In cases where conservative management is
indicated

5. Risks of over imaging
No direct relation between clinical symptoms and
imaging findings.
 The diagnosis is already established and imaging has already
been carried out.
 Repeat studies often lead to confusion in the mind of the
athlete and coach.
Non-significant abnormalities.
Different reports

6. The Travelling athlete
• Their documentation may be incomplete.
• Athlete may not know or remember, which type of injury
they had.
3 options :-
• The athlete carries his/her own ‘medical passport’.
• The injuries are registered in an electronic database.
• The information is sent from the previous doctor to the
current doctor by internet or by fax.

7. Imaging Modalities
• Plain Radiography and Conventional Arthrography
• Ultrasound
• Multidetector Spiral CT Scan
– Technique
– CT Arthrography
• Magnetic Resonance Imaging
– Technique
– Direct and Indirect Arthrography

8. Choice Of Imaging
Modalities

9. Plain Radiography and Conventional Arthrography
 Radiographs - diagnostic images needed for the
evaluation of sports injuries.
 The presence of loose bodies or degenerative joint
changes can easily be assessed with plain
radiography.
 Oblique views may be helpful
 Stress views may provide indirect evidence of
ligamentous injury.

10.  To confirm the results
after internal or external
fixation with reduction of
dislocations and
alignment of displaced
fracture fragments
 For monitoring the
progress of fracture
healing with callus
formation
 Detection of soft tissue
calcification after severe
muscle trauma

11.  The lack of soft tissue contrast-resolution
 When complications of the healing process occur,
such as infection or avascular necrosis, the role
of plain radiography may be limited and other
imaging techniques, such as bone scintigraphy
and/or MRI, may be useful for confirming the
diagnosis.
Conventional arthrography

12. The plain film
shows the
fractured
schaphoid
bone

13. • Ultrasound (US) plays a major role in sports
traumatology, helping the clinician to decide whether
the athlete should or should not return to training
and competition.
• US keeps its leading edge when dealing with muscle
pathology.

14. • High-frequency (13.5 MHz) probes are used to
perform musculoskeletal US examinations.
• Transverse and longitudinal slices are mandatory.
• Dynamic US study may be very helpful.
• US palpation is a very valuable tool.
• To avoid artefacts or pitfalls, comparison with the
contralateral side is necessary.

15. The recent addition of color-power
Doppler imaging to US has allowed for
the non-invasive study of blood flow
and vascularity within anatomic
structures and lesions.

16. US provides image guidance for
interventional procedures such as,
Drainage of fluid collections
Drainage of Cysts
Sclerosis of neovascularity
in painful chronic tendinosis

17.  Limited depth of penetration and the small, static
scan field
 If the structure to be visualized is large (e.g., large
intramuscular hematoma) or deeply localized (e.g.,
hip joint)
o Extended field of view ultrasonography (EFOVS)
 Other disadvantages of ultrasound include
o Operator dependency
o Less graphic images
o Selective and often incomprehensible
documentation and
o The inability to penetrate osseous structures

19. Ultrasound image showing a rotator cuff tear. A
full thickness tear of the supraspinatus tendon
(between the cursors, thick arrow) is shown, where the
tendon traverses the humeral head (thin arrows).

20.  CT imaging, is a valuable imaging
tool for the evaluation of all kinds
of sports injuries.
 Very fast image acquisition times
of large volumes with
submillimeter section thickness
have become the norm.
 It is an effective method of
documenting injuries particularly
in complex bony structures.

21.  Slice thickness : 0.75mm – 1mm
 Rotating X-ray tube
 Computer then processes the
data
 Technical advances

22. • All reconstruction methods offer a more effective
display of complex anatomic and pathologic
structures.
• It may be helpful for the assessment of
comminuted fractures, improving visualization of
the fracture’s extent and location, shape and
position of the fracture fragments and the
condition of articular surfaces.

23. CT Arthrography
 Intra-articular injection of iodinated contrast
material mixed with 1 ml of a 0.1% solution of
epinephrine is performed under fluoroscopic
observation.
 The volume of contrast medium injected depends
on which joint is studied:
o Shoulder: 10–15 ml;
o Wrist: 5 ml;
o Hip: 10 ml;
o Knee: 20 ml;
o Ankle: 6–12 ml

24.  After injection of contrast material, patients are
asked to perform full-range mobilisation of the
joint.
 Anteroposterior, lateral and oblique views are
routinely obtained to image the entire articular
cavity.
 Subsequently, multidetector CT is performed.

25. Advantages of CTA
 The major advantage of CTA for the assessment
of the cartilage is the excellent conspicuity of
focal morphologic cartilage lesions.
 Other potential advantages of spiral CTA,
o The short examination time,
o The availability at short notice (short waiting list)
o Limited degree of imaging artefacts

27. CT image shows in
3-dimensions the
bony morphology in
a case of anterior hip
impingement.

28. Equipment and techniques for MRI vary
widely, and although it is generally
accepted that high field strength
magnets provide the highest quality
images, there has been considerable
advancement in the technology of low
field strength systems over the past
few years, greatly improving their

29.  A complete MR examination
requires that images be
obtained in the axial, coronal
and sagittal planes.
 Excessive rotation of a limb,
inappropriate positioning of
imaging planes may result in
images which are difficult to
interpret.

31.  Spin echo(SE), gradient echo(GRE) and inversion
recovery(IR) sequences
 T1- weighted, T2- weighted, proton density and
short T1 inversion recovery(STIR) sequences
 Fat- suppressed and fat- saturated sequences

32.  The musculoskeletal system, especially in the
extremities, is not influenced by motion, and,
as a consequence, motion artefacts are rare.
 Contrast-enhanced MR studies lead to a
prolonged examination time and high costs,
and therefore, the use of intravenous contrast
agents is not indicated when evaluating a
sports lesion.

33. Recently,
 Diffusion Tensor Imaging (DTI)
 T2-mapping,
 Spectroscopy,
 Blood-oxygenation- level-dependent (BOLD)
imaging, and
 Molecular imaging

34. • It is not always being well
accepted by patients, of being
incompatible with dynamic
manoeuvres and of not
always being possible in
emergency conditions.
• It provides the evaluation of
an entire anatomical area –
bone structures included – but
is only good for the study of a
limited part of the skeleton.

35. Direct and Indirect Arthrography
 MR arthrography is a technique which is
mainly used in the shoulder, wrist, ankle,
knee and hip joint.
 Two different techniques are described –
o Direct MR arthrography
o Indirect MR arthrography

36. Coronal plane MRI
image diagnoses a
tear of the medial
meniscus (long
arrow), with a
meniscal fragment
displaced within the
joint (dotted arrow).
Note the normal
lateral meniscus
(short arrow).

37. Safety, Availability and Economic
Aspects
 Ionizing radiation is harmful and there is no safe
lower threshold of radiation
 Examinations on children
 Therefore, when clinically appropriate, the
alternative use of safer nonionizing techniques
(such as ultrasound and MRI) or of low dose
radiography/CT techniques must always be
considered

38.  MRI findings may have a significant impact on
diagnosis and treatment planning.
 Appropriate selection of patients will probably
yield similar results in other anatomic locations.
 The advancements in MRI technology may
expand the range of usefulness of this modality,
leading to even greater utilization of MR imaging
in patients with sports injuries, and, eventually, to
reduced costs and greater availability.

39.  Neurological investigation
o Electromyography
o Nerve conduction studies
o Neuropsychological testing
 Muscle assessment
o Compartment pressure testing
 Cardiovascular investigation
o Electrocardiography
o Stress electrocardiography
o Echocardiography
 Respiratory investigation
o Pulmonary function tests

40.  Clinical Sports Medicine,
Peter Brukner & Karim Khan
 Imaging of Orthopedic
Sports Injuries, F. M.
Vanhoenacker, M. Maas,
J.L.Gielen.
 Sports Injuries : the Role of
Imaging in Diagnosis and
Treatment, Dr Paul Jenkins,
MA MD FRCP, Medical
Director
 Diagnostic Imaging of Sports
Injuries, Matthew D.
Richardson, D.C., DACBR,
Director of Clinical
Radiology, Palmer Florida
Campus.