India / Dr. Naga Varaprasad Vemuri

European Society of Radiology: Sports imaging is the main theme of IDoR 2019. In most countries, this is not a specialty in itself, but a focus within musculoskeletal radiology. In your country, is there a special focus on sports imaging within radiology training or special courses for interested radiologists?

Naga Varaprasad Vemuri: Sports imaging as such is not a specialty in India but is a very important integral part of musculoskeletal (MSK) radiology and imaging. A few Advancing Paediatric Educator eXcellence (APEX) teaching hospitals and corporate hospitals have started short fellowships of MSK imaging, including sports imaging.

ESR: Please describe your regular working environment (hospital, private practice). Does sports-related imaging take up all, most, or only part of your regular work schedule?

NVV: I work in a private tertiary care hospital and attached to a private medical college as an Honorary Professor of Radiology. In our hospital, sports imaging represents about 30 to 40% of MSK imaging work.

ESR: Based on your experience, which sports produce the most injuries that require medical imaging? Have you seen any changes in this regard during your career? What areas/types of injuries provide the greatest challenge to radiologists?

NVV: In India, especially in our region, most sports injuries that require medical imaging are caused by cricket, volleyball, football and athletics practice.

ESR: Please give a detailed overview of the sports injuries with which you are most familiar and their respective modalities.

NVV: The modalities we work with to diagnose these injuries are x-ray, ultrasound and magnetic resonance imaging (MRI). We also work with computed tomography (CT) in a few cases. We encounter both acute and chronic injuries. The spectrum of injuries ranges from simple soft tissue contusions to fractures, the most common of which are bone stress injuries, ligament sprains and tendon avulsions. Ligament sprains in the ankle are very common in runners, fast bowlers and football players. We also see quite a lot of hyperextension injuries of finger tendons and ligaments, and FOOSH (fall on an outstretched hand) injuries sometimes. Plain radiograph (x-ray) is the first line of investigation after thorough clinical examination and is very useful in diagnosing fractures, including avulsions and stress-related fractures. We use ultrasound extensively for finger injuries, especially tendon and ligament avulsions and also for superficial ligament injuries of the ankle, Achilles tendon and also for rotator cuff injuries of the shoulder. MRI is very helpful in diagnosing stress-related findings very early and in cases where plain radiographs are inconclusive. We use MRI for twisting injuries of the ankle to diagnose medial and lateral ligament complex injuries as well as high ankle sprains, also in cases of knee injuries, mostly Pivot shift and hyperextension injuries to confirm and grade cruciate and collateral ligament injuries. We also use MRI and in the shoulder for rotator cuff, biceps-labral complex and ligament injuries.

ESR: What diseases associated with sporting activity can be detected with imaging? Can you provide examples?

NVV: Imaging can help detect many diseases associated with sporting activity, for example, MRI in bone bruise and contusions, most of the ligament, tendon and cartilage injuries of all joints. Superficial ligaments and tendon avulsions are well depicted on ultrasound. Stress fractures and obvious fractures are visible on a simple plain radiography. We can use CT for problem-solving to confirm tiny avulsion fractures, chronic stress fractures and in vertebral injuries.

ESR: Radiologists are part of a team; for sports imaging this likely consists of surgeons, orthopaedists, cardiologists and/or neurologists. How would you define the role of the radiologist within this team, and how would you describe the cooperation between radiologists, surgeons, and other physicians?

NVV: We should be part of the team undoubtedly. We need clinical information to have specific protocols of, as an example, the history of Pivot shift injury which directs radiologists to design protocols for anterior cruciate ligament (ACL) and other related structures. At the same time, imaging detects occult lesions, which are not clinically evident although the patient is symptomatic, like bone bruise or stress injuries.

ESR: The role of the radiologist in determining diagnoses with sports imaging is obvious; how much involvement is there regarding treatment and follow-up?

NVV: I can say it is increasing, as image-guided intra-articular interventions like platelet-rich plasma (PRP) injections, anaesthetic and steroid injections are increasing. Imaging and radiologists play a crucial role in follow-up to assess the progress.

ESR: Radiology is effective in identifying and treating sports-related injuries and diseases, but can it also be used to prevent them? Can the information provided by medical imaging be used to enhance the performance of athletes?

NVV: Early detection of subtle findings will prevent major injuries. I have no idea if imaging enhances athletes’ performance, but it certainly prevents breakdowns. Helping to take proper measures may retain the performance.

ESR: Many elite sports centres use cutting-edge medical imaging equipment and attract talented radiologists to operate it. Are you involved with such centres? How can the knowledge acquired in this setting be used to benefit all patients?

NVV: In our region, we have no specific centres like that. We have all the high-end equipment in our hospital. To acquire specific skills, I did a visiting fellowship under Dr. Stephen Pomeranj at Proscan, USA, one of the most reputed centres abroad, and also a sports imaging course at NYU Langone Medical Center, and a checklist workshop in MSK sports imaging given by Dr. David Stoller, Director of Orthopaedic and Musculoskeletal Imaging for Beverly Radiology, Northern California. This knowledge definitely helps my patients.

ESR: The demand for imaging studies has been rising steadily over the past decades, placing strain on healthcare budgets. Has the demand also increased in sports medicine? What can be done to better justify imaging requests and make the most of available resources?

NVV: This is a big burden. Prevention of sports injuries is the first measure. We must educate and train sports amateurs and athletes to prevent injuries as much as possible. Meticulous knowledge about the injury mechanism and proper clinical examination must direct specific investigation to look for specific structures. A simple radiograph or ultrasonography may be enough, most of the time.

ESR: Athletes are more prone to injuries that require medical imaging. How much greater is their risk of developing diseases related to frequent exposure to radiation and what can be done to limit the negative impacts from overexposure?

NVV: Most of the time, the pathologies are diagnosed with ultrasound and MRI, which emit no radiation. Plain radiographs taken in given clinical situations are focused to local body parts, with protection to other areas. Low dose CT scans that emit low radiation are available. However, for any investigation involving radiation, the important principle of ALARA (As Low As Reasonably Achievable) will be followed and the risk-benefit analysis is always useful.

European Society of Radiology: Sports imaging also applies to sports-related injuries of the brain. In case you are familiar with this, please also answer the following questions:

ESR: Which sports have the highest risk of inducing brain injuries?

NVV: Kickboxing, karate and close fielding in cricket present the highest risk.

ESR: What imaging modalities do you use with traumatic brain injury specifically in athletes?

NVV: The initial investigation is a CT scan. In some cases where no obvious CT scan findings are collected in a symptomatic patient, MRI can be used to detect axonal injury and non-haemorrhagic brain contusion.

ESR: What can be learned from sports-related injuries that can be applied to a broader use, for example those sustained through automobile or other accidents that cause traumatic brain injury?

NVV: Sports injuries and traumatic injuries differ mostly in intensity of brain damage. CT and MRI are complementary in both situations. CT is better for bone fractures, and MRI is better for axonal injuries and non-haemorrhagic contusions.

ESR: How have advances in brain imaging allowed you to predict patient outcomes more accurately?

NVV: Robust and fast sequences like compressed parallel imaging helped us in getting MRI scans in shortest scan time, which is very important in patients with head injury, where patient movement is an important limiting factor. Newer generation gradient echo-based sequences like susceptibility-weighted imaging (SWI) are very useful in picking up subtle axonal injuries and very helpful in diagnosing parenchymal, extra-axial, subarachnoid and intraventricular bleeds.