When you hear the term “imaging,” what immediately springs to mind? Broken bones? Bum knees and elbows? Concussions?

According to The Merck Manual by Merck & Co (Whitehouse Station, NJ), more than 10 million sports injuries are treated annually in the United States. Most are caused by overuse, followed by plain old smackage. Sports medicine in America has become—pardon the pun—a booming health care enterprise.

Sports imaging today goes far beyond radiographs of fractures. Although X-rays still smoke out broken bones quite nicely, diagnostic pictures are equally nifty for predicting injury, fine-tuning training, customizing equipment to an athlete’s needs, and visualizing hard-to-diagnose stress fractures. Meanwhile, the arrival of digital image management and the Internet has lofted the definition of sports imaging to a whole new level.

>Where the Toys Are
Portability and affordability mean sports can now have sophisticated modalities at on-site medical facilities. The Olympics, the NBA, and NASCAR are just three that do. The primary appeal lies in immediate diagnosis of game injuries, thereby eliminating a hospital trip to image something that otherwise would not sideline a player. Consider what happened last April at Talladega Superspeedway in Alabama when 29 drivers crashed into each other. The drivers were examined at the infield medical facility. One received two stitches, and racing resumed after a 40-minute delay.

The more money and publicity that are involved in a sport, the more likely medical imaging equipment will be present at its venues. The Olympic Polyclinic at the 1996 Atlanta games was the first Olympics at which MRI and ultrasound were available. The 2000 Polyclinic in Sydney boasted the first CT. The 2002 Winter Games in Salt Lake City featured an OEC MiniView 6800 compact C-arm and a 1.5T Signa EchoSpeed MRI from GE Medical Systems (GEMS of Waukesha, Wis), DirectView DR 9000 digital X-ray and DR PACS from Kodak Health Imaging (Rochester, NY), and ATL/HDI 5000 SonoCT ultrasound from Philips Medical Systems (Bothell, Wash). National Stadium in Yokohama, Japan, installed a Philips 1.5T MR scanner for the World Cup soccer final last June.

Many professional teams own their own equipment, too, primarily X-ray for breaks and ultrasound to detect muscle and rotator cuff tears as well as tendon inflammation.

“First-level triage for a dozen universities and nine professional sports teams uses Fluoroscan mini–C-arms, from football teams to baseball, basketball, soccer, and hockey,” says Perry Tomasetti, senior product manager for Hologic Inc (Bedford, Mass). Football players especially like having X-ray available at their games, he says, because they step on each other’s hands a lot, and broken fingers are common. Tomasetti recalls an incident involving the Chicago Bears a few years back, however, that broke with form.

“It was the last game of the season. A player had made a cut to avoid getting hit by somebody. In doing so, he fell to the ground in pain. We ran very quickly to the locker room where a Fluoroscan was standing ready. We found immediately that his fibula was broken up near the fibula head.

“The orthopedic surgeon was really kind of puzzled, because the player obviously had not sustained a hit to his knee,” Tomasetti continues. “Because of the real-time nature of the Fluoroscan picture, the surgeon was able to scan down the lower limb and see very quickly that the player had a lot of laxity in his ankle. It turned out that it was the realignment of forces through the fibula, because of the laxity of his ankle, that caused the fibula to break near the knee.

“The immediate plan—made there in the locker room—was that in the off-season, they would tighten up his ankle joint and cast him for his fibula fracture; he would be off a certain amount of months and then start rehab. He understood the fullness of the problem right there in the locker room before he even left, and he knew the injury wasn’t going to be a career-ender.”

>Fixes on the Fly
Dean Cummings, MD, is an orthopedic surgeon with the Orthopedic Clinic Association PC, a group practice in Phoenix. As the physician for Arizona State University’s sports department, Cummings sees plenty of elbow and knee injuries—and more.

“We have a lot of baseball players and wrestlers,” he says. “I’ve seen an incredible amount of injuries, from all different types of sports. I’ve seen a javelin stuck through somebody’s leg.”

Primarily, Cummings uses MRI and a Kodak CR system to image them. “We use a lot of MR with collateral ligament injuries and CR to do Telos examinations,” he says. The latter consist of putting an athlete’s elbow or knee at stress on a Telos machine and taking serial films. The advantage of doing that with CR, he says, is “being able to actually mark the film itself by the computer and then document exact space between the joints as you’re looking at them and opening them up.”

Duane Pitt, MD, is the orthopedic spinal surgeon in the group and the local spine surgeon for the San Francisco Giants, who conduct spring training in Arizona. The Orthopedic Clinic Association “has gone completely digital,” Pitt says. “If I obtain a film on a Giants player here, it can be viewed by his main orthopedic surgeons in San Francisco within minutes. That’s one of the biggest advantages when you’re talking about multiple teams who are in Arizona during the off-season for spring training. If a football player ends up with an ankle fracture while playing, he can be imaged quickly and the films can be read very quickly.”

Cummings adds that if he is at an away game, one of his players goes down, and he wants to look at a previously done image, “all I need to do is grab it from ASU through the Internet and compare it with the film on the sidelines.”

In fact, Pitt says, “I think every facility in the country will need to become digital to accommodate their athletes.”

>Bad Training, Improper Equipment
Elite athletes, like the rest of us, suffer from overuse injuries and physical quirks that affect performance. The difference is, they have to correct theirs to win. That’s another way imaging pays off.

Take long-distance sports. “One of the interesting things we noticed was in runners who run more than 75 miles per week,” says Nancy Major, MD, associate professor of musculoskeletal imaging and orthopedic surgery at Duke University (Durham, NC). “All of them were training for ultramarathons—50K, 50-mile, and 100-mile races. Three of the group had findings on a physical examination of regular lumbar spine disease, and it was attributed to having sciatica.” However, Major continues, “when the MR was done on one person, a sacral stress fracture was found. The others had MR also, and they too had sacral stress fractures. All along they’re thinking they have disc disease; they can’t run through their pain, they’re walking around the hall with this waddling gait because they’re in pain, and so it’s probably occurring much more commonly than we think. Making the diagnosis is key, and it’s a very easy diagnosis to make with MR.”

Erik Moen, PT, CSCS, is director of health services for Carmichael Training Systems (CTS of Colorado Springs, Colo). CTS is the coaching service of Chris Carmichael, trainer of four-time Tour de France champion Lance Armstrong, and the United States Postal Service Team. “Running is very different from bicycling,” he says, “but the similarities between the issues of overuse are pretty close. Overuse injuries often come as a result of a combination of things: improper training, musculoskeletal challenges, and improper equipment fit. Those factors need to be considered when diagnosing or working with an overuse injury for bicycling. Such things as leg-length discrepancy play a part, as do bony or muscular asymmetries.”

Errol Toran, DC, of Excel Chiropractic at Medical on 42nd Street (New York City), often treats such problems in athletes. He describes a common pelvic distortion that can impact sports performance. “Two ilia are completely counterrotated—one rotates back, one rotates forward. The result of the ilium that rotates posteriorly is that the sacrum tends to fall to that side, [and] the spinal column’s going to fall with gravity to the same side. You can’t be walking sideways, so your body compensates and goes the other way. You can’t be walking that way sideways, and it compensates back the other way. So now you have these lateral curves, otherwise known as scoliosis.”

Toran says such posterior rotation translates into “patellar femoral syndromes and knee pain on that side. The side that rotates anteriorly lifts the ischium and tensions the hamstring, which means a cyclist is going to develop hamstring and calf problems on the side of anterior rotation. Under load of intervals [a training technique involving timed bursts of speed], those minor distortions become magnified. I see it in dancers as well. A guy who is lifting a 100-pound woman overhead and has a scoliosis because of pelvic distortion—think about how that magnifies over time and over repetitive stress trauma. But this is all predictable from X-rays. The problem can be alleviated by [determining] which side they have their center of gravity to.

“Traditionally,” he continues, “when people take X-rays, they’re lying down. But for a sports application, that is useless. Most sports are weight-bearing, so for us, it’s essential that we evaluate the patients in a weight-bearing stance.

“When I take a set of X-rays, I take them full spine, where the patient is standing. Then I’ll have the patient move, turned laterally, and shoot the lumbar pelvic, the thoracic, and then the cervical. When I take these pictures, I can see distortions in the pelvis. You can tell so much and use it as a predictive indicator for future pathology of vulnerability.”

>Reinventing the Wheel
Rory A. Cooper, PhD, is a professor at the University of Pittsburgh, chairman of its Department of Rehabilitation Science and Technology in the School of Health and Rehabilitative Sciences, and director of the Human Engineering Research Laboratories of the VA Pittsburgh Healthcare System. Cooper won the bronze medal in wheelchair racing at the 1988 Paralympic Games in Seoul, Korea, and four gold medals at the 2002 National Veterans Wheelchair Games. A world-renowned authority on wheelchair design and technology, Cooper designed the first racing wheelchair built entirely of nonwheelchair parts and is considered a pioneer in that sport.

Wheelchair racers average 19 mph in marathons and achieve speeds of 26 mph on the track and 55 mph downhill in road racing using only hand propulsion. Their most common injuries occur in the shoulder. Cooper’s associate is Michael Boninger, MD, associate professor of Rehabilitation Science and Technology, Mechanical Engineering; medical director for the Human Engineering Research Laboratories; and executive director for the Center for Assistive Technology. They both have a special research interest in this subject.

“We prefer MRIs for our research, because we’re looking to gain insights into injuries before they happen,” Boninger says. “By using an MRI, we wonder what precursors to injuries we see. What subtle changes are there, and can we use that information to prevent injuries? We have been able to find that certain people are developing MRI findings related to how they’re propelling their chairs; therefore, we might be able to give them advice to prevent those findings from becoming something more significant, like a rotator cuff tear.”

Cooper adds, “One of our goals is to either change the equipment or change the training. In wheelchair racing, athletes tend to replace both their racing wheelchairs and their regular chairs more frequently than the average person, because they can detect changes in the chair more effectively.”

Boninger explains that the team has done significant research on videography, “as in preventing injuries through motion analysis. Dr. Cooper’s done a lot of research on enhancing the performance of wheelchair racers through motion analysis.” In one study, Cooper proved that wheelchair racers had a gross upper-extremity mechanical efficiency of more than 30%, compared with the average for normal activities of 2% to 8%, and that their wrist velocity on impact with the pushrim was so powerful, it could cause enough spike to injure a racer’s shoulder.

>A League of Injuries of Their Own
Boninger says that with wheelchair racers, the injuries he and Cooper see most are rotator cuff tendinitis, rotator cuff tears, and osteolysis of the distal clavicle. He calls the latter “a unique injury that seems to be prevalent in wheelchair hand racers.”

Other sports can claim fairly exclusive injuries as well. Elite skiers, for example, sometimes sustain a bit of nastiness called a boot-top fracture. “These are usually from high-velocity falls in downhill skiing,” explains Steve Sirr, MD, a radiologist with Consulting Radiologists Ltd, a group that practices at Abbott Northwestern Hospital (Minneapolis). “It’s a really significant fracture.

“The modern ski boot is usually made out of fiberglass and tightly bound to the ski,” Sirr says, “so that when the skier falls forward at a high velocity, the tibia and fibula are fractured at about the midpart of the bone. It requires a lot of speed—maybe 20, 30 mph.”

According to a 2001 study by the Steadman Hawkins Sports Medicine Foundation (Vail, Colo), 600,000 skiing injuries occur annually. Some 20% to 30% are knee injuries, and knee fractures of the top of the shinbone are eight times more common than previously thought. Boot-top fractures are best imaged, Sirr notes, “with just plain X-rays. They’re very easily diagnosed. It’s just a particularly unusual fracture because it occurs at a very strong part of the tibia and fibula. It would put a skier out for a season, for sure.”

Although such sports as hockey and motocross also rate high on the Bang-O-Meter, cycling just might take the prize. Competitors negotiate hairpin turns and vertical concrete embankments horizontally and zoom down mountains at highway speeds while wearing little more than underwear, a ploy to improve aerodynamic efficiency that sometimes backfires. Hockey players and motocrossers at least have the advantage of padding.

Carmichael Training Systems’ Moen says there is great variety in classic cycling injuries. “When you’re coming off the bike at 40 mph and hitting the ground or whatever’s on the side of the road, anything can happen. You have to be very careful with your diagnosis, [because sometimes], internal damage occurs, such as femoral artery and hepatic ruptures.” Moen says two of the most common cycling injuries, though, are “abrasion [affectionately known as ‘road rash’] and the clavicle fracture. It doesn’t take advanced imaging to diagnose that, by any means.”

>Because it Feels So Good When it Stops?
The experts agree on one trait shared by all high-level athletes regardless of sport: They will play through pain. So pervasive a condition is pain that it often becomes difficult for athletes to distinguish between a normal amount and a degree requiring medical intervention.

Tying for first prize in the Most Belligerent Sportspeople category are NASCAR drivers, who compete with serious injuries to keep their Winston Cup points positions, and cyclists, who must finish every stage of weeks-long European tours to maintain their World Cup and UCI rankings.

Moen says, “An athlete I was working with had crashed in a road race and sustained a clavicle fracture and rib fractures. Those were diagnosed by X-ray in the emergency room. The patient was discharged and proceeded to fly out the next day on a business trip. I encouraged her to have a follow-up with an orthopod, who decided by fluke to do a general medical exam. He discovered she had a collapsed lung.”

Ball players are also notorious pooh-poohers of pain. At Duke, the basketball players are imaged with MRI before and after the NCAA season for findings of jumper’s knee. “With sports that have a lot of jumping and landing,” Duke’s Major says, “tendons or ligaments can become degenerated over time. Several of them did indeed have changes that would be diagnostic of jumper’s knee. What we find is that they don’t complain about the pain. They think that at the end of the game, they’re supposed to have some, so they’re soaking this or icing that, and that’s ‘expected’ when you’re playing at that level. There are kids here on scholarship; many of them have aspirations to play professionally, and if you start complaining that you have pain somewhere, you’re going to get rested and benched. That’s not a good situation when you’re a high-caliber athlete looking for a future beyond college basketball.”

It is a universal sentiment. According to the Official Report of the XXVII Olympiad, 1,648 visits were made for imaging at the 2000 Polyclinic in Sydney. A quarter were from Australians, and most of the rest were from Russians, Chinese, Mexicans, Egyptians, and Poles—visitors who do not exactly enjoy cutting-edge health care at home.

So where were the stars?

Despite the top-drawer doctors and state-of-the-art equipment available at such facilities, injured athletes in serious contention are reluctant to visit them. One reason is that they might not receive clearance to resume competition.

“When I was on the medical squad for the 1990 Goodwill Games, athletes would tell me off the record that they weren’t going to go in the clinic,” says Cooper, who recently found himself in the same position. “I competed in the ’88 Paralympics. I’d have to be dead before they pulled me out. A nasty flu bug went through both the whole Olympic and the Paralympic teams. What choice do you have? You train for years. You get the flu, you just have to work through it and hope the other guys have the flu, too. Olympic athletes don’t get the money until they get the gold medal.”