You are on page 1of 9

Kerslake_Eu Musc 29/04/2010 12:09 Page 82

Sports Medicine

The Role of Imaging in Sports Medicine

Tom D Turmezei, David Yu and Robert W Kerslake

Department of Radiology, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre

Abstract
Imaging plays a vital role in the diagnosis and management of sporting injury. There are several factors unique to sports medicine that need to
be taken into account when considering imaging of the injured athlete, such as sporting technique and the biomechanical stresses associated
with any given activity. Close liaison between the referring physician and the reporting radiologist is vital not only for selecting the most
appropriate imaging technique, but also for accurate interpretation of imaging findings. We discuss the current status of imaging in sports
medicine, focusing on challenges to the referrer, challenges to the radiologist and the roles of the most commonly used modalities.
Interventional techniques and recent advances are also discussed for each modality. Finally, there is recognition that imaging needs to be
promoted in sports medicine research in order to help establish a firm evidence base for practice.

Keywords
Imaging, sports medicine, athletic injury, ultrasound, magnetic resonance imaging

Disclosure: The authors have no conflicts of interest to declare.


Received: 27 January 2010 Accepted: 12 April 2010 Citation: European Musculoskeletal Review, 2010;5(1):82–8
Correspondence: Tom D Turmezei, Department of Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
E: tom@diagnosticradiology.eu

Imaging plays a vital role in the diagnosis and management of While injuries affect athletes at all levels, professionalisation has
sporting injuries. Early diagnosis can reduce rehabilitation time and contributed significantly to changes in imaging strategies.
long-term disability, so developments in imaging have had the knock- Performance pressures have pushed for the earlier detection of injury
on effect of an improvement in the outcome of injury episodes. in order to limit time away from activity and to avoid disability and
Combined with increased understanding of the biomechanical factors deformity that may detract from career length, peak performance or
involved in athletic activity, advances in imaging have contributed to activity enjoyment. This has prompted imaging to be performed at an
earlier and more accurate diagnosis, but in doing so have uncovered early stage when clinical evaluation can be non-specific, and as a
findings of undetermined saliency in a spectrum of ‘normal’ to result has led to unsuspected sub-clinical findings being revealed that
‘abnormal’ that pose a challenge to the interpreting radiologist. In this pose a direct question of relevance to the interpreting radiologist.
article, we discuss the developing role of imaging in the management
of sports injuries and address specific challenges to the referring Challenges to the Referrer
physician and the reporting radiologist in this field, illustrated with Good working relationships are vital to ensure as much information as
several pictorial examples. possible is gleaned from imaging studies, starting with discussion with
the radiologist about the clinical assessment. This should include details
Imaging of Sports Injury of the mechanism of injury, usual activity levels, previous injuries,
In addition to episodes of acute trauma, sporting activity involves sporting technique and salient positive and negative examination
repetitive actions that place specific biomechanical stresses on the findings. Close liaison with a focus on the specific area of interest leads
body according to the demands of the activity and the technique of to appropriate imaging being performed, sometimes with multimodality
the athlete. It is essential for both the referring physician and the assessment being required. The patient can then be reviewed with the
reporting radiologist to be aware of these factors as they can be related results and re-imaged should there be further indication.
to recognisable patterns of injury, such as repetitive impact loading in
long-distance running that can lead to tibial stress fractures.1 Another The decision of when to image should ideally be guided by evidence-
example is repetitive overarm throwing in baseball pitchers and javelin based practice, but in many areas of sports medicine this is still to be
throwers that can lead to superior labral anteroposterior (SLAP) lesions. established.3 A sensible approach has been suggested by Orchard et
In such cases, it is important for both physician and radiologist to be al.4 and Anderson et al.5 in terms of when to image:
aware that throwing athletes exhibit a different pattern of shoulder
injury from the general population in the form of posterosuperior • when a diagnosis is in question;
glenoid impingement.2 The risk of a multiplicity of injuries occurring • to determine the extent of injury;
from a single mechanism must also be recognised. • with treatment failure;

82 © TOUCH BRIEFINGS 2010


Kerslake_Eu Musc 29/04/2010 12:10 Page 83

The Role of Imaging in Sports Medicine

• in the presence of warning signs and symptoms; Figure 1: Plain Radiography in the Assessment of
• for objective documentation of disease, progression or resolution Ankle and Foot Pain
(such as in medicolegal situations); and
• for pre-operative planning.4,5 A B

In many clinical scenarios, the most suitable image modality is yet


to be determined. For example, the shoulder has historically
been imaged with plain radiography, ultrasound (US), computed
tomography (CT), CT arthrography, magnetic resonance imaging (MRI)
and MR arthrography,2 with rotator cuff pathology being reliably
demonstrated with both US and MRI. The precise choice of modality
may also depend on local expertise, equipment, safety, financial
constraints and patient tolerance; therefore, it is important to discuss
options with the radiologist. A: Lateral radiograph of the ankle showing calcaneonavicular bony tarsal coalition in a
skeletally immature individual. Compare with B, in which there is no coalition.
B: Lateral radiograph of the ankle of a footballer taken in the assessment of an acute injury,
Challenges to the Radiologist showing a bony spur on the superior aspect of the talar neck. These lesions are found in
The greatest challenge to the reporting radiologist is to be able to both symptomatic and asymptomatic athletes.

correctly identify imaging features that are associated with pain,


injury and disability, and thus related to relevant symptomatic Table 1: Specialist Areas of Computed
pathology in a spectrum of imaging findings. It is important that subtle Tomography Application
abnormalities that relate to an episode of injury are not overlooked,
while asymptomatic pathology should be underplayed (but not Specialist Areas of Computed Tomography Application
ignored), especially if it does not require intervention. Increasing age Sternoclavicular joint dislocation
can also present difficulties in interpreting findings that in a younger Femoral anteversion*
individual may be more confidently called pathology, such as with Leg length (use of the CT scout image only)
degenerative change in the menisci of the knee, which can be Spondylolysis assessment (see Figure 3)
Complex fracture assessment
misinterpreted as a tear.6
Pre-operative planning
Imaging of operative metalwork
The difficulty in defining the ‘normality’ of findings in the imaging of
Head, body and spinal trauma
athletes has led to recurring debate in the medical literature. There
Guidance for deep body injections
appears to be a spectrum of appearances from completely normal
*Found in developmental hip dysplasia, it limits the external rotation required in ballet,
that ranges through anatomical/congenital variants, physiological for example.
change to ‘normal for athletes’, sub-clinical pathology and  relevant
symptomatic and asymptomatic pathology. These are discussed with to stress as a means of resisting increased load, providing an example
examples below. of physiological adaptation in elite athletes10 – further discussion on
adaptive bone stress is included below. Another example of
Medicolegal situations in which there is the requirement for objective physiological change seen with imaging is muscle imbalance that can
documentation of disease progression or resolution can also be develop with poor training technique or single-handness of an activity,
encountered.5 There is very little discussion on this topic in the which can subsequently lead to overuse injury.11
medical literature, yet it also poses a challenge to the radiologist, who
must consider the consequences of an unsuspected finding that has ‘Normal for Athletes’
not yet caused injury or detraction from performance. Ankle ‘spurs’ are a common finding in athletes, being found on the
superior aspect of the talus in up to 60% of football players (see
Imaging Findings – What Is Normal? Figure 1B). Such lesions are thought to be either osteophytes formed
Anatomical/Congenital Variants from repetitive microtrauma or enthesophyte development from
Knowledge of underlying anomalies and variants that can predispose recurrent capsular or ligamentous traction.12 However, anterior
to injury or pain on performance provides important information for tibiotalar spurs have also been found in a significant proportion
clinical management. For example, abnormal joint alignment and (45–59%) of asymptomatic athletes,13 and so may represent part of a
congenital joint dysplasia are known risk factors for injury and can spectrum that is ‘normal for athletes’ at one end with painful
lead to osteoarthritis.7 Tarsal coalition can present with hind-foot symptoms of anterior ankle impingement at the other.
pain, multiple sprains and subtalar joint stiffness as a result of
abnormal biomechanical stresses through the foot. While suspected Sub-clinical Pathology
coalition can be shown with plain radiography (see Figure 1A), further MRI assessment of the shoulder in asymptomatic baseball pitchers
cross-sectional imaging with CT or MRI can be performed if the has been shown to demonstrate labral abnormalities that have thus
diagnosis is equivocal. In such cases appropriate imaging can lead to been assumed to be ‘non-clinical’.14 Impact and torsional loading of
correct diagnosis and treatment with acceptable return to activity.8,9 joints has been implicated in the development of osteoarthritis in
athletes with undiagnosed joint injury, but not in those who have
Physiological Change undertaken moderate habitual exercise, by middle age.7 Osteophytes
An MRI study of Olympic fencers has demonstrated that bone develops and meniscal abnormalities have also been demonstrated in the
trabecular adaptations and an increased marrow volume in response knees of asymptomatic volunteers.15

EUROPEAN MUSCULOSKELETAL REVIEW 83


Kerslake_Eu Musc 29/04/2010 12:10 Page 84

Sports Medicine

Figure 2: Plain Radiography in the Assessment of Tendon Rupture and Avulsion

A B C

A: Lateral radiograph of the knee in a 41-year-old male with sudden loss of function and painful clicking while running. The high-lying patella indicates complete patellar tendon rupture.
Further imaging with dynamic ultrasound (US) can give useful information on the gap distance between tendon ends and the presence of contralateral tendinopathy that may predispose
to further injury.18
B: Anterior–posterior (AP) radiograph of the pelvis in an adolescent female with sudden pain and loss of function in the left posterior thigh while exercising. There has been avulsion of the
left hamstring insertion at the ischial tuberosity; avulsion injuries of this type are most common in the unfused skeleton. Understanding the timing of such injuries is also important, because
a more chronic injury can have an aggressive appearance similar to Ewing’s sarcoma, which occurs in the same age group.19
C: Lateral radiograph of the middle finger of a 50-year-old male after a hyperflexion injury with a residual mallet finger deformity. Imaging shows an abnormality at the dorsal base of the
distal phalanx, indicating an avulsion fracture of the extensor tendon attachment. If there is mallet finger deformity with normal radiographic appearance, US or magnetic resonance imaging
may be indicated for further assessment of extensor tendon congruity.

Figure 3: Spiral Multidetector Computed Tomography Acquisition Computed Tomography of the Lumbar Spine in a
21-year-old Right-arm Cricket Bowler

A B C

A. Multiplanar reconstruction (MPR) technology allows for re-formatting along the axis of the pars interarticularis without the need for reverse-gantry scanning. There is a small spondylolytic
defect in the right L4 pars interarticularis with a more pronounced defect on the left at the same level. These defects are well demonstrated by CT1 and are characteristically seen in young
fast bowlers.22
B. Parasagittal MPR through the right pars interarticularis demonstrating the spondylolytic defect seen in A.
C. Parasagittal MPR through the left pars interarticularis demonstrating more pronounced spondylolysis compared with the right-sided defect. These appearances suggest that the left defect
is the older of the two. MRI was used to obtain further information on the age of these lesions (see Figure 4).

Relevant Symptomatic Pathology tears demonstrated on MRI of the knee, for example.17 This is
The aim is for the radiologist to correctly identify this, especially if it is important because lesions that are not symptomatic should not
a finding that could be considered sub-clinical if the athlete was necessarily be treated clinically.
asymptomatic. Importantly, recognised patterns of change related to a
specific activity should not be dismissed as ‘normal for the athlete’ if Plain Radiography
they are symptomatic, as has been demonstrated with spondylolysis Apart from soft-tissue injuries, such as muscle tears and superficial
and spodylolisthesis in the spine in elite female gymnasts.16 tendinopathy (when US is more appropriate), first-line imaging for
sports injuries is nearly always with plain radiography, which provides
Asymptomatic Pathology a lot of information for minimal radiation exposure. Omitting plain
Gross pathology of osteoarthritis, rotator cuff disease and radiography in the initial assessment can also lead to errors in
intervertebral lumbar disc protrusions have all been demonstrated in diagnosis.5 Plain radiography is cheap, quick and readily available and
asymptomatic individuals and may not be relevant to the injury gives low radiation exposure. Disadvantages of this technique include
episode at the time of imaging.5 The incidence of asymptomatic the production of a flattened 2D image; although radiographs have
pathology has also been shown to increase with age, as in meniscal been historically associated with poor soft-tissue information, recent

84 EUROPEAN MUSCULOSKELETAL REVIEW


Kerslake_Eu Musc 29/04/2010 12:11 Page 85

The Role of Imaging in Sports Medicine

Figure 4: Parasagittal Magnetic Resonance Images of the Same Patient as in Figure 3

A B C D

(A) T1 and (B) short tau inversion recovery (STIR) parasagittal images show bony oedema (low signal on T1 and high signal on STIR) in the right L4 pars interarticularis, the less pronounced of
the defects on computed tomography (CT). The L4 vertebra is identified with an asterisk (*). (C) T1 and (D) STIR parasagittal images show bony sclerosis (low signal on T1 and STIR) in the right
L4 pars interarticularis, the more pronounced of the defects on CT.
These findings confirm that the left defect is chronic while the right defect is most likely subacute, an early stress fracture in the stages of bony adaptation. Unilateral L4 injuries are
particularly common in fast bowlers, especially on the side opposite to the bowling arm, with the phase of injury determinable by the presence of oedema around the defect on STIR
imaging. Bilateral and multilevel defects are nonetheless still frequent.22,30

Figure 5: Magnetic Resonance Imaging in the Assessment of Internal Knee Derangement

A B C

A: Sagittal 3T magnetic resonance imaging (MRI) of a normal right knee with an intact anterior cruciate ligament (ACL). 3T imaging has significant advantages in lesion detection, while also
providing greater spatial resolution and shorter acquisition time. It is now applied unequivocally to the knee, but is not universally established for all body parts.
B: Sagittal 3T MRI of the right knee in a 21-year-old male patient who sustained a valgus/rotational injury during wake-boarding. There is loss of integrity of the ACL, in keeping with a
complete acute tear. Higher-field-strength imaging has been shown to improve the diagnostic accuracy of MRI for ACL rupture.29
C: Coronal 3T fat-saturation MRI of the same patient as in B, showing a peripheral full-thickness vertical tear through the lateral meniscus (arrow). The patient had also injured the medial
meniscus and the posterolateral corner (not shown), emphasising the importance of being aware of the possibility of multiple abnormalities from a single-injury episode.

advances in digital imaging have provided much improved soft-tissue Computed Tomography
detail and contrast. Although CT is the main source of iatrogenic radiation dose in the
general population and therefore not an insignificant cancer risk,20 it
Beyond the assessment of acute bony trauma, plain radiography is is nonetheless valuable in the assessment of bony pathology and
valuable in the assessment of prostheses, accessory ossicles, soft- traumatic injuries to the head, spine and body. Specialist areas of CT
tissue calcification, heterotopic ossification, bone stress (such as in application are listed in Table 1.
osteitis pubis), tendon rupture and avulsion (see Figure 2), bony
coalition (see Figure 1A), degenerative joint disease, tumours and Strengths of CT include the fact that it is quick and readily available.
suspected foreign body. The finding of a normal plain radiograph also Advances in computer algorithm processing and image reconstruction
adds value through the exclusion of such conditions.5 have reduced artefacts caused by metallic prostheses, while

EUROPEAN MUSCULOSKELETAL REVIEW 85


Kerslake_Eu Musc 29/04/2010 12:11 Page 86

Sports Medicine

Figure 6: Ultrasound in the Assessment of Muscle Injury Using Panorama Sweep Technology

Panorama from a longitudinal sweep of the extensor compartment of the anterior thigh of a 21-year-old cricketer who had sustained a direct blow to this region six weeks prior to
examination. There is an area of heterotopic calcification (myositis ossificans) in the deep tissues of the anterior thigh that is casting acoustic shadowing (*), a finding related to a previous
injury episode. Distally there is fibre discontinuity with fluid-filled clefts in the vastus lateralis muscle (arrow), a finding related to the most recent injury.

multidetector CT (MDCT) has become standard practice, revitalising shown on MRI in the ankles and feet of volunteers whose normal
the use of CT in musculoskeletal imaging. MDCT technology has biomechanical forces were altered by the use of a unilateral
allowed for reduced scan times, better spatial resolution and greater orthosis.25 Sub-clinical bone stress injury has also been demonstrated
tissue contrast, while also enabling 3D reconstruction and multiplanar on MRI in the feet of ballet dancers, in whom it correlated with ankle
reformatting (MPR) that has negated the need for image acquisition in pain.26 Bone marrow oedema can in fact be demonstrated in a
non-axial planes, such as in reverse-gantry scanning for detection of multiplicity of locations with the caveat that we still do not know what
spondylolysis (see Figure 3).21 the norm is for certain athletic groups, and so its clinical significance
on MRI within the spectrum of imaging findings in sporting injury is
CT-guided intervention is useful for areas of the body that are too under continuous debate.27
deep or awkward for US penetration, such as in facet joint, sacroiliac
joint, pudendal nerve and iliopsoas tendon injection. CT arthrography In terms of the clinical application of MRI, good technical
can also be used for joints, such as the shoulder and knee, where its understanding and clinical integration between physician and
accuracy is as good as that of MRI for the assessment of meniscal radiologist is integral in order for the right MR technique to be
pathology.21 It provides a useful alternative for those who are performed. For example, proton density fast spin-echo sequences are
unsuitable for MRI. especially accurate for meniscal and cruciate pathology in the knee
(see Figure 5), while fat suppression techniques such as short tau
Magnetic Resonance Imaging inversion recovery (STIR) and fat saturation imaging are excellent for
Due to its non-ionising nature, multiplanar acquisition capability, identifying bone oedema (see Figure 4) and cartilage abnormalities.28
excellent anatomical detail and superb soft-tissue imaging
characteristics, MRI has moved to the forefront of imaging in sports Advances in gradient-echo MR sequences, such as steady-state free
medicine. Muscles, tendons, ligaments, bursae, cartilage, bone precession imaging, have allowed for faster and higher spatial
marrow and growth plates are all excellently visualised with this resolution 3D volume acquisition with fewer of the artefacts that
technique. It has become the gold standard modality in the previously detracted from this technique. 28 This can be used
investigation of overuse injury, virtually eliminating the role of bone effectively in MR arthrographic assessment of shoulder instability.
scintigraphy,11 and it has also been instrumental in increasing our Direct MR arthrography has nearly completely replaced diagnostic
understanding of painful hip conditions such as labral tears and arthroscopy in the management pathway of shoulder and knee
chondral injuries.23 disorders, while indirect MR arthrography, in which intravenous
injection of contrast medium gradually perfuses into the joint space
MRI has played an important role in developing understanding of the over time, may have some future application in the imaging of small
relevance of bone stress reaction because of its ability to identify joints such as the wrist and ankle.31
bone marrow oedema. Bone is a dynamic structure that responds to
biomechanical stresses with functional adaptations that depend A specific advantage of MRI over US is in its ability to image multiple
on strain rate and magnitude and are thought to have a strong pathologies at once, such as shoulder rotator cuff injury with a
genetic influence. Early bone stress is generally thought to be a concomitant labral tear, which can thus reduce the possibility of
protective adaptation; however, continued bone stress can lead to failed shoulder surgery. However, MRI is a confined examination
microtrabecular damage that outweighs the repair process, (more so than CT) and can induce claustrophobia, as well as placing
progressing to early stress fracture, complete fracture and, with a limit on the size of subject that can be examined. Recent advances
continued activity, to chronic non-union such as spondylolysis in the have seen the introduction of less restrictive open MRI scanners,
spine (see Figures 3 and 4).1 sometimes in the enterprising role of interactive and interventional
MR imaging.32 In the former, joints can be imaged under direct stress
Bone stress reactions have been demonstrated on MRI in the ankles or dynamically, while in the latter MR is used to guide injection
and feet of asymptomatic individuals,24 while they have also been (although this does require specialist MR-compatible equipment).

86 EUROPEAN MUSCULOSKELETAL REVIEW


Kerslake_Eu Musc 29/04/2010 12:12 Page 87

The Role of Imaging in Sports Medicine

Open MRI certainly allows imaging in positions not possible in Figure 7: A Spectrum of Ultrasound Findings in the
conventional scanners. Achilles Tendon

Upright positional MRI has been used to demonstrate the effect of A B


load-bearing on the lumbar spine,33 and may find further application
in the evaluation of the load-bearing biomechanics of body
positioning in sport. Other areas of research with MR have involved
the use of 7T scanning, for example in the assessment of trabecular
bone microarchitecture in the knees of Olympic fencers, as
described above.10

Ultrasonography
In recent years, US has been increasing in popularity in sports C D
imaging.34 It is appropriate as the first-line imaging for muscle tears
and superficial tendinopathy and also has an important role in the
assessment of general tendon disorders.18,35–37 Other areas of US
application include groin injuries, entheseal injuries, ligamentous
disease, avulsion fractures, stress fractures, foreign bodies and
synovitis.38 Small and superficial soft-tissue masses and ganglia are
also well suited to US examination.

Like MRI, US has the advantage of being a non-ionising technique with E F


excellent soft-tissue imaging characteristics. A unique feature of US is
its capacity for realtime, dynamic imaging that can demonstrate
features such as tendon glide, subluxation, soft-tissue impingement
and hernia protrusion.36 Conversely, the dynamic nature of imaging
means that its full value can only be appreciated by the
ultrasonographer at the time of examination.

High-frequency transducers (9–17MHz) have improved spatial


resolution significantly, while miniaturised, albeit less powerful, G H
portable scanners are suitable for examining patients immediately
after injury or even on the field of play.18,38 New ‘sweep’ technologies
can provide extended panoramic views (see Figure 6) as well as 3D
reconstructions, while the power Doppler mode allows for sensitive
vascular assessment (see Figures 7E and 7F). Insurmountable
obstacles to US include its inability to assess bone, marrow and
cartilage disease. The lack of information in depth is another
defining limitation.
(A) Longitudinal and (B) transverse ultrasound (US) of a normal Achilles tendon.
(C) Longitudinal and (D) transverse US of an Achilles tendon with moderate tendinosis.
There is mild fusiform enlargement of the tendon with preservation of the
The most frequently cited criticism of US is that inexperience can
fibrillar microarchictecture.
lead to loss of sensitivity in the detection of subtle abnormalities. 38 (E) Longitudinal and (F) transverse assessment with power Doppler function shows
intratendon neovascularity. The precise pathophysiology of neovascularity in abnormal
Like MRI, good technical understanding and clinical integration is
tendons is not understood, but it is not seen in normal tendons.18
essential, however, the additional aspect of ‘driving’ the (G) Longitudinal and (H) transverse US of an Achilles tendon with a partial tear. The tendon
has a narrowed configuration with some continuity of fibres noted. Fluid (asterisk) is
machine to produce optimum image quality also has to be
interposed between the torn tendon edges, and a clump of calcification is also noted (arrow).
considered, emphasising the importance of training and experience Dynamic examination is also important in determining appropriate management, since
non-apposition of the tendon edge with passive plantarflexion may require surgical
for safe and accurate examination. 38 This is especially relevant as
management.36 Chronic tendon abnormalities can persist on imaging, even with good
the increasing availability and practicality of US has led to its functional recovery, and so imaging findings should be interpreted with reference to
careful clinical assessment.39
regular use by practitioners across a number of specialist fields
outside radiology.
Conclusion
US has an important role in guiding intervention, such as for the While the principles of imaging in general radiology also apply for
injection of local anaesthetics and corticosteroids into joints, tendon imaging in sports medicine, there are factors unique to the imaging
sheaths and bursae. US-guided joint injection can be performed of athletic injuries that must be considered by those directly
in preparation for MR or CT arthrography and also to guide aspiration involved in their care. These include the biomechanical stresses of
of collections, cysts and ganglia. Recent advances in US research different activities, the technique of the individual athlete and the
include realtime sonoelastography, which may offer further increasing motivation to return to activity earlier. Both the sports
insight into mucoid degeneration in tendon disorders, and the physician and radiologist require a good understanding of these
use of contrast agents to demonstrate low-volume blood flow in factors in order to initiate appropriate imaging, accurately diagnose
tendon neovascularity.40 and treat athletic injury. Close liaison is vital to enable appropriate

EUROPEAN MUSCULOSKELETAL REVIEW 87


Kerslake_Eu Musc 26/04/2010 11:23 Page 88

Sports Medicine

and focused imaging and to help the radiologist in the challenge of


interpreting relevant symptomatic findings in a spectrum through Tom D Turmezei is a Specialist Registrar in Diagnostic
Radiology who is beginning sub-specialist training in
anatomical/congenital variants, physiological change to ‘normal
musculoskeletal radiology at Nottingham University
for athletes’, sub-clinical pathology and relevant symptomatic and Hospitals. His professional interests include human
asymptomatic pathology. anatomy and undergraduate medical education. He
also co-authored the Oxford Handbook of Clinical
Medicine and the Oxford Handbook of Clinical
Plain radiography remains an essential first-line tool for most injuries. Specialties. Dr Turmezei has a keen interest in the
CT, although best avoided in younger athletes because of the high imaging of athletic injury, and is aiming to undertake a
master’s in sports medicine.
radiation load, still has several targeted roles. MRI and US are
non-ionising techniques with excellent soft-tissue imaging
David Yu is training in radiology at Nottingham
characteristics that are ideal for the imaging of sports injury, with University Hospitals, after previously studying anatomy
choices between the two often depending on cost, local expertise at Brighton and Sussex medical schools. His interest in
sports has encouraged him towards subspecialising in
and equipment. Bone scintigraphy is now virtually redundant as MRI
musculoskeletal radiology, developing a special interest
provides more information with far greater anatomical detail and in sports medicine imaging. Dr Yu graduated from Barts
without the risks associated with ionising radiation. and the Royal London School of Medicine and Dentistry,
having also completed an intercalated BSc in
pharmacology at King’s College London.
Interventional techniques in sports imaging are continually
developing, with MR arthrography now having nearly replaced
Robert W Kerslake is a Consultant Musculoskeletal
diagnostic arthroscopy of the shoulder and knee. The non-ionising Radiologist who has worked at Queen’s Medical Centre,
aspect and broad reproducibility of MRI will also continue to Nottingham for the last 16 years. He has a background
in clinical magnetic resonance imaging (MRI) and MRI
make it an exciting research tool in sports imaging. Finally,
research and has implemented his sports imaging
imaging must be encouraged in the research activities of sports expertise for teams at both local and national levels.
medicine in order to develop a greater understanding of changes in This has included acting as an imaging reviewer for the
England Cricket Board and the English Institute of Sport
athletes that span from physiological to pathological, and hence
at Loughborough University.
create a solid platform for the practice of evidence-based medicine
in the future. n

1. Datir AP, Stress-related bone injuries with emphasis on professional baseball pitchers, Am J Sports Med, sports: general concepts, Eur J Radiol, 2007;62(1):6–15.
MRI, Clin Radiol, 2007;62(9):828–36. 2002;30(1):66–73. 28. Gold GE, Hargreaves BA, Beaulieu CF, Protocols in sports
2. Roger B, Skaf A, Hooper AW, et al., Imaging findings in the 15. Beattie KA, Boulos P, Pui M, et al., Abnormalities magnetic resonance imaging, Top Magn Reson Imaging,
dominant shoulder of throwing athletes: comparison of identified in the knees of asymptomatic volunteers using 2003;14(1):3–23.
radiography, arthrography, CT arthrography, and MR peripheral magnetic resonance imaging, Osteoarthritis 29. Oei EH, Nikken JJ, Verstijnen AC, et al., MR imaging of the
arthrography with arthroscopic correlation, AJR Am J Cartilage, 2005; 13(3):181-6. menisci and cruciate ligaments: a systematic review,
Roentgenol, 1999;172(5):1371–80. 16. Bennett DL, Nassar L, DeLano MC, Lumbar spine MRI in Radiology, 2003;226(3):837–48.
3. McCrory P, Evidence-based sports medicine, Br J Sports the elite-level female gymnast with low back pain, Skeletal 30. Engstrom CM, Walker DG, Pars interarticularis stress
Med, 2001;35(2):79–80. Radiol, 2006;35(7):503–9. lesions in the lumbar spine of cricket fast bowlers,
4. Orchard JW, Read JW, Anderson IJ, The use of diagnostic 17. Kornick J, Trefelner E, McCarthy S, et al., Meniscal Med Sci Sports Exerc, 2007;39(1):28–33.
imaging in sports medicine, Med J Aust, 2005;183(9):482–6. abnormalities in the asymptomatic population at MR 31. Zoga AC, Schweitzer ME, Indirect magnetic resonance
5. Anderson IJ, Read JW, Atlas of Imaging in Sports Medicine, 2nd imaging, Radiology, 1990;177(2):463–5. arthrography: applications in sports imaging, Top Magn
ed., Sydney: MacGraw-Hill, 2008. 18. Bianchi S, Martinoli C, Abdelwahab IF, Ultrasound of Reson Imaging, 2003;14(1):25–33.
6. Hodler J, Haghighi P, Pathria MN, et al., Meniscal changes tendon tears. Part 1: general considerations and upper 32. Beaulieu CF, Gold GE, Interactive and interventional sports
in the elderly: correlation of MR imaging and histologic extremity, Skeletal Radiol, 2005;34(9):500–12. medicine imaging, Top Magn Reson Imaging, 2003;14(2): 115–30.
findings, Radiology, 1992;184(1):221–5. 19. Stevens MA, El-Khoury GY, Kathol MH, et al., Imaging 33. Alyas F, Connell D, Saifuddin A, Upright positional MRI of
7. Buckwalter JA, Lane NE, Does participation in sports features of avulsion injuries, Radiographics, 1999;19(3):655–72. the lumbar spine, Clin Radiol, 2008;63(9):1035–48.
cause osteoarthritis?, Iowa Orthop J, 1997;17:80–89. 20. Berrington de González A, Darby S, Risk of cancer from 34. Nofsinger C, Konin JG, Diagnostic ultrasound in sports
8. Saxena A, Erickson S, Tarsal coalitions. Activity levels with and diagnostic x-rays: estimates for the UK and 14 other medicine: current concepts and advances, Sports Med
without surgery, J Am Podiatr Med Assoc, 2003;93(4): 259–63. countries, Lancet, 2004;363(9406):345–51. Arthrosc, 2009;17(1):25–30.
9. Elkus RA, Tarsal coalition in the young athlete, Am J Sports 21. Buckwalter KA, Current concepts and advances: 35. Bianchi S, Poletti PA, Martinoli C, et al., Ultrasound
Med, 1986;14(6):477–80. computerised tomography in sports medicine, appearance of tendon tears. Part 2: Lower extremity and
10. Chang G, Pakin SK, Schweitzer ME, et al., Adaptations in Sports Med Arthrosc, 2009;17(1):13–20. myotendinous tears, Skeletal Radiol, 2006;35(2):63–77.
trabecular bone microarchitecture in Olympic athletes 22. Hardcastle P, Annear P, Foster DH, et al., Spinal 36. Robinson P, Sonography of common tendon injuries, AJR
determined by 7T MRI, J Magn Reson Imaging, 2008;27(5): abnormalities in young fast bowlers, J Bone Joint Surg Br, Am J Roentgenol, 2009;193(3):607–18.
1089–95. 1992;74(3):421–5. 37. Megliola A, Eutropi F, Scorzelli A, et al., Ultrasound and
11. Koh ES, Lee JC, Healy JC, MRI of overuse injury in elite 23. Brukner PD, Crossley KM, Morris H, et al., 5. Recent magnetic resonance imaging in sports-related muscle
athletes, Clin Radiol, 2007;62(11):1036–43. advances in sports medicine, Med J Aust, 2006;184(4):188–93. injuries, Radiol Med, 2006;111(6):836–45.
12. Hayeri MR, Trudell DJ, Resnick D, Anterior ankle 24. Zubler V, Mengiardi B, Pfirrmann CW, et al., Bone marrow 38. Allen GM, Wilson DJ, Ultrasound in sports medicine – a
impingement and talar bony outgrowths: osteophyte or changes on STIR MR images of asymptomatic feet and critical evaluation, Eur J Radiol, 2007;62(1):79–85.
enthesophyte? Paleopathologic and cadaveric study with ankles, Eur Radiol, 2007;17(12):3066–72. 39. Khan KM, Forster BB, Robinson J, et al., Are ultrasound
imaging correlation, AJR Am J Roentgenol, 2009;193(4):W334–8. 25. Schweitzer ME, White LM, Does altered biomechanics and magnetic resonance imaging of value in assessment
13. Cheng JC, Ferkel RD, The role of arthroscopy in ankle and cause marrow edema? Radiology, 1996;198(3):851–3. of achilles tendon disorders? A two-year prospective
subtalar degenerative joint disease, Clin Orthop Relat Res, 26. Elias I, Zoga AC, Raikin SM, et al., Bone stress injury of the study, Br J Sports Med, 2003;37(2):149–53.
1998;(349):65–72. ankle in professional ballet dancers seen on MRI, BMC 40. Klauser AS, Peetrons P, Developments in musculoskeletal
14. Miniaci A, Mascia AT, Salonen DC, et al., Magnetic Musculoskelet Disord, 2008;9:39. ultrasound and clinical applications, Skeletal Radiol, 2009
resonance imaging of the shoulder in asymptomatic 27. Vanhoenacker FM, Snoeckx A, Bone marrow edema in (Epub ahead of print).

88 EUROPEAN MUSCULOSKELETAL REVIEW


EUMusc_subscription_EU Musc 30/04/2010 16:04 Page IBC1

European
Musculoskeletal Review
Now available on subscription

Published bi-annually, European Musculoskeletal Review


endeavours to support clinicians, physicians and related
healthcare professionals in continuously developing their
knowledge, effectiveness and productivity.

Directed by an Editorial Board comprising internationally


respected physicians, European Musculoskeletal Review’s
peer-reviewed articles aim to assist time-pressured
physicians to stay abreast of key advances and opinion
in musculoskeletal practice.

Ensure that researchers, students and fellow physicians


at your institution enjoy the educational benefits:

• Concise review articles detail the most salient


developments in musculoskeletal medicine.
• Latest opinion and practice guidelines.
• Detailed bibliographies make it a valuable reference and
research tool.
• Breadth of coverage helps professionals to stay abreast
of developments beyond their core specialities.

Subscription Rates

Online and print Online only

European
Full Institutional (Europe) €180 €170 Musculoskeletal Review
Full Institutional (the Americas) US$225 US$210 Volume 4 • Issue 2

Full Personal (Europe) €80 €70


Full Personal (the Americas) US$100 US$85
Advances in the
Understanding and Treatment
of Rotator Cuff Disease

Print and online subscriptions cover two print editions per Edward G McFarland, Juan Garzon-
Muvdi, Zhigang Dai and Pingal Desai

annum and full online access to the electronic version of Epitopes of Autoantigens
and Their Role in Initiation
European
and Propagation of
Systemic Autoimmunity Musculoskeletal Review
the journal for a 12-month period. John G Routsias and
Athanasios G Tzioufas
Volume 5 • Issue 1

Is There Still a Place for


Diagnostic Ankle Arthroscopy?
Sjoerd AS Stufkens, Peter AJ
de Leeuw and C Niek van Dijk

Professionals working in the musculoskeletal field in Europe Percutaneous Vertebral Body


Augmentation Using Injectable

qualify for free subscriptions. Bone Cement for Vertebral


Compression Fractures
John Yeh

Rehabilitation in Osteoporotic
Targeting RANKL in Subjects – Myth or Reality?
Post-menopausal Osteoporosis Olivier Bruyère, Jean-Yves Reginster,
René Rizzoli Jean-Louis Croisier, Jean-Michel
www.touchbriefings.com Crielaard and Didier Maquet

Minimally Invasive Foot and


Ankle Surgery
Nicola Maffulli, Umile Giuseppe
Longo and Vincenzo Denaro

10 Years of Computer-assisted
Total Knee Replacement –
A Gimmick or Still an
Emerging Technology?
Thomas Mattes, Wolfhart Puhl and

Order online or download a pdf subscription form at:


Ralf Decking

Current Trends in Osteoarthritis


Imaging – An Update from a

www.touchbriefings.com/subscriptions
Radiological Viewpoint
Ali Guermazi, Daichi Hayashi,
Michel D Crema and Frank W Roemer
www.touchbriefings.com
EU_Musc_Cover_EU Musc 6mm spine 29/04/2010 11:27 Page FC1

European Musculoskeletal Review Volume 5 • Issue 1 • 2010


European
Musculoskeletal Review
Volume 5 • Issue 1

Rehabilitation in Osteoporotic
Subjects – Myth or Reality?
Olivier Bruyère, Jean-Yves Reginster,
Jean-Louis Croisier, Jean-Michel
Crielaard and Didier Maquet

Minimally Invasive Foot and


Ankle Surgery
Nicola Maffulli, Umile Giuseppe
Longo and Vincenzo Denaro

Saffron House
10 Years of Computer-assisted
6–10 Kirby Street
London Total Knee Replacement –
EC1N 8TS
A Gimmick or Still an
EDITORIAL Emerging Technology?
Tel: +44 (0) 20 7452 5303
Fax: +44 (0) 20 7452 5050 Thomas Mattes, Wolfhart Puhl and
Ralf Decking
SALES
Tel: +44 (0) 20 7452 5230
Fax: +44 (0) 20 7452 5606
Current Trends in Osteoarthritis
E-mail: info@touchbriefings.com
www.touchbriefings.com Imaging – An Update from a
Radiological Viewpoint
ISSN: 1754-5072
Ali Guermazi, Daichi Hayashi,
Michel D Crema and Frank W Roemer
www.touchbriefings.com