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SPORTS MEDICINE RADIOLOGY
problem solving and definitive diagnosis in the shoulder. It has two main indications: shoulder pain that cannot be identified by ultrasound, and labral tears. Standard MRI gives a good overview of the shoulder joint and has a high sensitivity and specificity for rotator cuff pathology, and combined with arthrography it has increased diagnostic accuracy for rotator cuff tears. Mimics of rotator cuff pathology, such as greater tuberosity fractures and nerve impingement, can also be visualised by MRI (4,16). n MR arthrography: This is the investigation of choice for identifying labral tears of the shoulder; contrast is injected into the shoulder before imaging and diagnosis is made if contrast leaks through the labral tear. MR has the further advantage of showing the associated ligamentous injuries. Bankart lesions are visualised with a high degree of accuracy, and tears such as superior labral anteroposterior (SLAP) tears and Perthes lesions may also be diagnosed. Injuries of the glenohumeral ligaments and long head of the biceps are also seen, making this the preoperative imaging modality of choice (16,17,18,19). Sports-related damage to these structures is seen most frequently in contact sports such as rugby. Fig. 4 shows a typical image obtained with MR arthrography.
Imaging the elbow The elbow joint is not often imaged in sports medicine. The main indications (apart from trauma) are chronic pain and localisation of loose bodies. n Plain radiographs: These are useful for identifying loose bodies and calcification in soft tissues. n Computerised tomography: CT is rarely used in the elbow except in cases of acute trauma. n Ultrasound: Ultrasound is used extensively in the elbow as the soft tissues in the elbow are very superficial. It is used to confirm the diagnosis of epicondylitis, and identify synovitis and effusions. Less commonly it is used to identify ulnar nerve pathology and olecranon bursitis (20). n Magnetic resonance imaging: In epicondylitis, MRI is used to identify the extent of tendon involvement, muscle tears or chondral lesions and to help differentiate these from collateral ligament damage. Other common
indications are osteochondral lesions of the elbow joint and ligamentous instability (20). n MR arthrography: This is used to locate loose bodies in the joint (4).
Imaging the wrist and hand The wrist consists of a complex set of joints with multiple superficial tendons and ligaments. Imaging of the hand can be difficult due to its complex anatomy the following modalities will yield valuable information. n Plain radiographs: These play an important role in the wrist, providing an overview of the bones (but little information about the tendons and ligaments). Apart from the normal frontal and lateral views, there are views for looking at specific bones and joints. The scaphoid series, as the name suggests, employs four views in different planes to image the scaphoid, and these increase sensitivity for diagnosing scaphoid fractures. Stress views are used in the wrist and thumb to identify ligament disruption. For acquiring more information, other modalities are required in addition (3). n Ultrasound: Ultrasound is used very frequently because the wrist structures are superficial. High-frequency ultrasound probes of 10–17Mhz are used. The common indications include de Quervain’s and other forms of tenosynovitis, evaluation of soft tissue masses such as ganglia, and tendon and ligament integrity (15,21). n Computerised tomography n Magnetic resonance imaging: MRI has become very useful for obtaining high-resolution images of hand and wrist pathology, but is used after ultrasound imaging. The modality is predominantly a problem-solving tool, that assesses the intrinsic ligaments. In scaphoid fractures, it has the highest diagnostic sensitivity and specificity, which is why there is a move to perform MRI of the wrist in clinically suspected scaphoid fractures with negative radiographs and in assessment of scaphoid non- union (4,5). MRI has also been used to identify avascular necrosis (AVN) of scaphoid fracture fragments and the lunate, known eponymously as Kienbock’s disease. MRI is used as a problem-solving tool also for chronic wrist pain in athletes. The patterns of bone and soft tissue oedema can point to unifying diagnoses such as ulnar
impaction syndrome (21). n MR arthrography: MRI contrast is injected into the proximal carpal row under fluoroscopic or ultrasound guidance and then high-resolution MR imaging is performed. Its main roles are in investigation of wrist pain, evaluation of the intrinsic ligaments of the proximal carpal row, and assessment of the triangular fibrocartilage complex (TFCC) (22,23). The contrast in the joint improves the resolution of ligaments, thereby helping identify carpal instability (4).
Imaging the hip and groin Hip and groin pain are common indications for imaging, especially for
Figure 5: MR scan of the groin showing osteitis pubis with marked inflammatory change in the origins of the adductors (arrowed).
Figure 6: MR scan of coronal section of the knee showing a bucket-handle tear of the medial meniscus with a large fragment (long arrow) displaced from the normal triangular meniscus (short arrow) into the intercondylar region. Intra-articular or mechanical symptoms generally require assessment by MRI.
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