Brazilian radiologists take on soccer injuries

A more stressful examination is hard to imagine. The patient is a star performer insured by his soccer club for Euro 60 million, but a suspected groin strain might force him to miss the Champions' League final in two weeks. The club's physicians call the radiology department every five minutes, while dozens of reporters and paparazzi line up outside the hospital, desperate for a scrap of news or photographic evidence of the damaged body part.

Imaging now plays a central role in the diagnosis and management of soccer injuries. MRI is the most valuable modality because of its multiplanar capabilities and high contrast resolution, but imaging top professional players is not for the faint-hearted or those in search of a comfortable life. It requires sound expertise, efficient organization, a rapid response, and a cool head. Radiologists in Brazil, home to the current world soccer champions, have extensive experience of this field, and they know what it takes to manage injuries.

"To do this job well, radiologists must pay particular attention in each and every case and must have a wide knowledge of the musculoskeletal system and sports medicine," said Dr. Armando de Abreu, chair of radiology at Hospital Mae de Deus in Porto Alegre. "A good working relationship between the radiologist and team physician is essential, and the service needs to be open 24 hours a day, even during weekends and holidays. We cannot go to see the games ourselves."

De Abreu and his colleagues have been involved in imaging soccer players for the past 12 years. The hospital has a dedicated osteoarticular imaging department with three musculoskeletal radiologists on staff. They perform x-ray, ultrasound, CT, and MR examinations for the top two local professional teams: Gremio (1983 World Club champions and twice Latin American champions) and Internacional (three times Brazilian champions). Both teams' stadiums are located close to the hospital, less than 10 minutes away by car. Radiologists there have examined many of the leading Brazilian stars who now play in Europe, and they cover all the national and international matches played in their state, Rio Grande do Sul.

At the RSNA meeting, held in Chicago in December, de Abreu and his colleague Dr. Marcelo Abreu, chief of the MRI section and coordinator of research at Hospital Mae de Deus, presented the details of a two-year follow-up study of 180 scans of soccer players. Given the shortage of information about soccer injuries in the medical literature, their findings are significant.

Half the cases involved muscles in the thigh, while 20% of scans were of the knee, 14% were of the ankle and foot, 8% were of the leg, and 7% were of the pelvis (pubis and hip). The posterior aspect of the thigh accounted for 51% of all muscle strain injuries, the adductor muscle for 33%, and the anterior aspect of the thigh for 16%. The most common muscle strains encountered in the lower limbs were hamstrings (61%), adductors (23%), quadriceps (16%), and calf (7%).

"Muscle strains are more frequent now, probably because of the increasing number of games per month and excessive training," Marcelo Abreu said. "Overuse injuries, such as stress fractures and pubic osteitis, are diagnosed more often. In the past, without MRI, those diagnoses were not made."

PREDICTING RECOVERY

MRI is by far the most commonly used modality at the hospital and can accurately predict an injured player's recovery time. The radiology department has two GE 1.5T Signa Horizon MR systems and one Siemens 1.5T Symphony Maestro Class scanner. During the two-year study, MRI accounted for about 78% of the total number of procedures, plain film for 18% of cases, and ultrasound and CT for the remaining 4%. Ultrasound is rarely used because it is not suitable for detecting small lesions.

The Brazilian doctors typically perform an x-ray when a player has a suspected fracture, particularly in the ankle or foot. Spine x-rays are taken of patients with back pain, and hip x-rays are used for hip pain to diagnose acetabular dysplasia, early osteoarthritis, and osseous avulsions.

Ultrasound is performed after MRI for controls in grade 2 and 3 muscle strains, but the doctors do not perform ultrasound routinely as the first-choice investigation for diagnosis of lesions in professional soccer players.

"Ultrasound misses a lot of grade 1 muscle strains, and that encourages the quick return of the players to the sport, causing reinjuries that take more time to heal completely," Marcelo Abreu said. "We believe that grade 1 strains are probably the most important to diagnose. They are very common, and if they are not treated properly, they can become chronic. That's why we developed a protocol for grade 1 strains that consists of sequences with local coils, small field-of-view, and thinner slices."

To predict a player's recovery time, the degree of strain is assessed based on the signal intensity. The average recovery time for a grade 1 strain of the hamstring is nine days; for a grade 2 strain, 18 days; and for grade 3, 28 days. Players with strains of the adductor muscles tend to return to the field relatively quickly. The typical recovery time is one month for a patient with compartmental syndrome and 42 days for a capsular tear.

The Porto Alegre team developed a formula that considers the longitudinal size of the lesions and can estimate the recovery time with good precision. This approach makes it possible to predict recovery in days with an accuracy of about 80%.

"Often, however, there is a conflict between the interests of the team and the player, and problems can get worse if players return to action too quickly," de Abreu said.

The radiologists try to work with team physicians to decide when a player is fit to return to action, explaining the need to correlate imaging findings with clinical signs and symptoms. But some physicians ignore the radiologists' recommendations, probably due to commercial pressures, de Abreu said.

Only about 1% of cases encountered in the department involve the head, but these injuries can be complex. Following trauma in a match, a 19-year old player underwent MR angiography, which showed ischemia in the brain. Other tests were normal, and traumatic dissection of the middle artery was correctly diagnosed. After eight months of a rest-and-aspirin regimen, the player made a full recovery.

The results of an MR examination are usually available to the soccer club within 30 to 60 minutes. At least one osteoarticular radiologist is on call during evening and weekend games. A STIR sequence is used in the axial and either sagittal or coronal planes, and the scan is completed in about eight minutes. The technologist conducts a physical examination of the player, localizes the pain center, places the coil on the injured site, and uses a marker on the skin. Technologists usually perform at least one control examination in each player, especially when a muscle strain is involved. If the strain is grade 2 or 3, an examination is typically done every 10 days.

"The interpretation is performed on a workstation because in our experience it has more sensitivity than film," Marcelo Abreu said. "The result is transmitted by cell phone and by paper. In muscle strains, we show the value of the formula that estimates the recovery time of the lesion."

This attention to detail and adherence to rigorous procedures and systems have contributed significantly to the radiology department's successful track record in diagnosing soccer injuries at Hospital Mae de Deus.

Bibliography

De Jonge MC, Maas M, Van Kuijk C. Diagnostic imaging of injuries and overuse in soccer players. Radiologe 2002;42(10):778-787. (German)

Fried T, Lloyd GJ. An overview of common soccer injuries. Management and prevention. Sports Med 1992;14(4):269-275.