MRI scans in Sports Medicine – use or abuse?

There was an interesting article in the New York Times this week that caught my eye, thanks to an alert from our Publisher at CJSM (thanks, Paul!)

In the article by Gina Kolata, a science journalist for the New York Times, Dr James Andrews, of the Andrews Institute for Orthopaedics and Sports Medicine, was quoted as saying ‘If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI.’

The article claims that Dr Andrews was involved in a piece of research where the pitching shoulders of 31 asymptomatic Professional Baseball pitchers were scanned using MRI, with findings of ‘abnormal shoulder cartilage’ in 90% of the shoulders, and ‘abnormal rotator cuff tendons’ in 87% of the shoulders. There was no indication as to whether or not this research was published.

Other clinicians are subsequently quoted, including Professor Bruce Sangeorzan, Vice Chairman of the Department of Orthopaedics and Sports Medicine at the University of Washington saying ‘an MRI is unlike any other imaging tool we use… It is a very sensitive tool, but it is not very specific. That’s the problem.’

In addition, Professor Christopher DiGiovanni, Sports Medicine and Orthopaedic Specialist at Brown University, is quoted as saying ‘It is very rare for an MRI to come back with the words “normal study” … I can’t tell you the last time I’ve seen it.’

Following quotes from these clinicans, the author goes on to make what some might call a leap of faith in then stating that ‘MRIs are not the only scans that are overused in medicine, but in sports medicine where many injuries involve soft tissues like muscles and tendons, they rise to the fore,’ the statement regarding ‘overuse’ having been drawn, presumably, from inferences from some of the clinicians quoted in the article.

Later on in the article, a retrospective study from 2005 by Bradley and colleagues  of 101 patients with chronic atraumatic shoulder pain is mentioned which examined the effect of pre-evaluation MRI on patient treatment and outcome, and concluded that MRI was not helpful as a screening tool for atraumatic shoulder pain before a comprehensive clinical evaluation of the shoulder.

In addition, another retrospective study from 2007 was mentioned by Tocci and colleagues who set out to prove the alternative hypothesis that rising accessibility of MRI may be resulting in it’s overuse by retrospectively reviewing 221 patients seen over a 3 month period for the treatment of a lower extremity problem. The authors concluded that ‘many of the pre-referral foot or ankle MRI scans obtained before evaluation by a foot and ankle specialist are not necessary.’

The New York Times article certainly seems to have sparked a flame of interest spreading amongst other newspaper and website authors and has been widely quoted in the few days since it has been published.

There is no doubt that there are a number of factors that could lead MRI scans to become overused as an investigation in the assessment of patients seen by Sports Medicine clinicians. These could include improved accessibility to MRI scanners, reduced cost for examinations, inadequate clinician history taking and / or examination skills, laziness on the part of clinicians in performing an appropriate assessment, financial incentives, patient pressure for scans, and defensive medical practice.

However, any clinician worth their salt surely recognises the need for an excellent history, targeted clinical examination, formulation of a differential diagnosis and appropriate investigation on the basis of these.

They would also surely realise issues regarding the sensitivity and specificity of MRI scans for detecting lesions, and the fact that the natural history of some lesions detected by MRI scans that have hitherto been undetectable is not well known, limiting the conclusions that can be drawn from some scans relating to treatment and prognosis.

In addition, the limitations of MRI scanning as a screening tool should also be known by responsible clinicians, although there is no doubt in my mind that some colleagues are using MRI scanning in a non-evidence based way for screening and that this may ultimately lead to unnecessary procedures and psychosocial harm.

I don’t agree with the quote from Dr Andrews implying that if one wants to operate on a pitcher’s shoulder then all one needs to do is order an MRI scan – good surgeons operate on patients, not scans, and should surely follow the time-honoured approach I have highlighted above.

The article by Kolata in the New York Times presents little if any evidence that MRI scans are indeed overused in Sports Medicine, and it is my opinion that the views of a few individuals plus a couple of retrospective studies don’t really form a convincing argument to support the inference in the title of author’s article, that MRIs are indeed overused in Sports Medicine.

It’s interesting that our Specialty was targeted in this article.

Is this a thinly-veiled attack on Sports Medicine clinicians?

What do our readers think?

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Sideline assessment of concussion and return to play – are we practising what we preach?

The seventh Rugby Union World Cup competition ended last saturday in a tense final between strong favourites, the famous New Zealand All Blacks, and France, the former holding out for a one-point win 8-7 over Les Bleues.

The game featured a number of injuries, but one caused more of a stir than most – the injury to the French number 10 Morgan Parra.

Parra took what appeared to be an accidental blow to the side of his head from the knee of All Blacks’ Captain Richie McCaw in a ruck, and appeared to be visibly concussed, looking shaky on getting up after receiving lengthy on-field medical attention. The incident can be seen in this video.

He was taken from the field of play and replaced by Trinh-Duc. Surprisingly, however, he re-appeared on the field after around 5 minutes and continued to play on for another 5 minutes until he experienced another knock during a tackle and eventually went off for good.

The circumstances surrounding his departure from the field in the first instance appear to be a little unclear. Parra thought that he had gone off for a blood injury, which would fit with him being allowed back onto the pitch later on in the absence of having suffered a concussive injury. Of course, there is no ‘concussion bin’ to allow time for observation and recovery prior to return to play. However, there is a ‘blood injury bin’ where players are permitted to have blood injuries attended to prior to return to the field as appropriate. To this viewer, it did appear that Parra had indeed suffered a concussive injury following the blow from McCaw’s knee, in which case it is surprising that he was allowed to re-enter the field of play.

Parra mentioned ‘I was bleeding a bit, I took a knock and I was a bit dazed,’ adding ‘I was trying to get out from under the ruck, I took a knee to the face, it wasn’t when (Ma’a) Nonu tackled me, but afterward. Did he (McCaw) mean it? I don’t know. I haven’t seen the footage. But it wasn’t from Nonu.’

Parra went on to mention ‘I wanted to come back on, but my neck and head were hurting, and then I took another kick to it … that’s how it goes. What can you do? I wasn’t targeted any more than last week. I know that when you play No. 10 and you weigh 80 kilos people go looking for you more.’

What is of great concern is that if Parra was indeed allowed back onto the pitch following a concussive injury, then this would been in direct contravention of the IRB’s own Concussion guidelines which clearly state that ‘Players suspected of having concussion must be removed from play and must not resume play in the match, ‘ and this would have occurred during Rugby’s showcase, the World Cup Final which was watched by record figures of TV viewers worldwide this year. The IRB guidelines are in agreement with the Concussion in Sport Group’s guidelines - see point 2.2 ‘On-field or Sideline Evaluation of Acute Concussion – (e) A player with diagnosed concussion should not be allowed to return to play on the day of injury.’

In the Concussion in Sport group’s guidelines, there is a caveat that adult athletes, in some settings, may return to play more rapidly providing certain conditions and a level of support may be met, but that there should still be the same management principles for return to play, starting with complete cognitive and symptom recovery. The issue of the appropriateness of return to play on the same day following an acute concussion is hotly debated, but there is no doubt that it still occurs. However, if Parra was indeed concussed, then return to play in the same match would have been in direct contravention of the IRB’s own Concussion guidelines.

Those of us who manage head injuries and concussion at the pitchside are well aware of the many difficulties of translating concussion guidelines into practice, especially when players get up and run off in the middle of assessments and such, but if Parra was indeed concussed, then surely he should never have been allowed back onto the field of play.

The Rugby Law blog was particularly vociferous on these events.

For those interested in the topic of Concussion in Sport, don’t miss the chance to view the recent Ovid Webcast with Margot Putukian and John D. Corrigan here.

Have you had problems and issues with interpreting and applying concussion guidelines to clinical practice?

CJSM would like to hear your experiences and opinions.

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London Prepares series – 2012 test events in full swing

With less than 300 days to go until the start of the London 2012 Olympics on the 27th of July, and the Paralympics on the 29th of August, London is entering the final stages of its preparation. The City has been hosting the ‘London Prepares’ test event series in advance of the games and these commenced in May this year with the 2011 UK Athletics 20km race walking championships and an invitational marathon. Since then, there have been a number of other events including equestrian, modern pentathlon, sailing, triathlon, badminton and various cycling events.

The latest treat on the calendar was the 2011 London Archery Classic held at Lords Cricket ground from the 3rd to the 10th of October, and I was on hand to view events for myself as a Sports Medicine event doctor last weekend.

Lords Cricket ground is better known in the UK and worldwide as the home of Cricket, so it was a little strange to see such a different audience in the famous old pavilion, usually occupied by members of the Marylebone Cricket Club (MCC) in their distinctive red and yellow striped jackets and sun hats. Despite the unfamiliar appearance of the spectators, this famous old venue was a wonderful place in which to see the athletes compete in the archery event. Perhaps it was fitting that, in such a prestigious place, the archers rose the occasion by putting in some excellent and memorable performances, including two new world records. Korea’s Im Dong-Hyun managed to break his own  72-arrow world record in the ranking round, scoring 693 and exceeding  his previous record by two points, and followed this up by helping to set a world record in the men’s team competition.

From the medical side of things, everything seemed to go very smoothly with no major problems, the classic representing an ideal opportunity for the medical team to get to grips with things at the venue and to make the fine adjustments necessary to systems and resources prior to the games proper.

As far as test events go, there are many to go this side of Christmas with handball, boxing, table tennis and fencing amongst others to feature. In the new year, spectators can look forward to many more competitions including gymnastics, cycling and aquatics events before some paralympics test events commencing in April.

It is always exciting to be involved in test events prior to the main spectacle to come, and it was a pleasure to be able to watch these world class athletes perform and to talk with the other support and coaching staff. I was even fortunate enough to try my hand at the sport on a much shorter range, managing to hit the target with each of my 3 arrows. Having said that, I don’t think that Im Dong-Hyun and his colleagues have much to fear.

Archery was reintroduced to the Olympic games in the 1972 Munich games following a 52 year hiatus thought to be due to a lack of uniform rules.

Ertan and Tuzun found a prevalence of injury of 56.8% in a questionnaire study of 88 archers at the 2000 Turkish archery championships, although were not specific about their definition of a reported injury. Mann and Littke reported an injury rate of 38.1 injuries per 100 competitors from a retrospective questionnaire of 21 archers who qualified for the Canadian world championship team in 1987. Most injuries are reported to occur in the upper extremities. Ertan and Tuzun found the fingers to be the most frequently reported body part to be injured, followed by the shoulder of the drawing arm. This pattern was further supported by National Electronic Injury Surveillance System findings from the US product safety commission 2007 which included hunting-related archery injuries.

Acute injuries include blisters in the fingers and contusions to the bow forearm caused by string touches, also known as ‘bow slap.’ Most archers wear protection on their bow forearm to prevent this injury. Chronic overuse injuries include tendinopathies (see Rayan G, in Southern Medical Journal) and compression neuropathies in the arm (see Toth C et al, in Sports Medicine). For a comprehensive review of the epidemiology of injury in archery, see Hildenbrand JC (IV) and Rayan GM Chapter 2 in Caine DJ et al ‘Epidemiology of Injury in Olympic Sports’ , Wiley Publishing.

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Concussion to consequence webinar – 12 days to go!

The Ovid Concussion to Consequence Webinar will be live in 12 days’ time, with Margot Putukian, Director of Athletic Medicine at Princeton University, Past President of the American Medical Society for Sports Medicine, and member of the NFL’s Head, Neck and Spine Committee joining John D. Corrigan, Professor in the Department of Physical Medicine and Rehabilitation at Ohio State University and Editor-in-Chief of the Journal of Head Trauma Rehabilitation in a 60 minute discussion on topics related to concussion in sport.

The webinar goes live at 12:00hrs EST on Tuesday the 18th of October, and can be accessed here.

Dr Margot Putukian comments :

‘Concussion is a challenging injury to assess and manage, and the research is evolving at an exponential pace.  The upcoming webinar will be an opportunity to discuss the definition of concussion as well as some of the essentials regarding recognition and management of this injury.  We will discuss a comprehensive approach which includes the pre-season planning as well as sideline and post-injury assessments, return to play considerations, and finally prevention and areas of future research.  We will hope to provide a comprehensive review of a very challenging and important topic.’

In addition to these topics, there will be further discussion on the lifetime risks associated with repeated episodes of concussion, and emerging data on the delayed consequences of early episodes of concussion. Some of the evidence presented will be extrapolated from studies of armed forces veterans and other groups who have a higher incidence of early traumatic brain injuries than the general population.

It’s been over 172 years since Baron Guillaume Dupuytren, perhaps better known for his description of Dupuytren’s Contracture and his treatment of Napoleon Bonapart’s haemorrhoids, described the differences associated with unconsciousness following traumatic brain injury in individuals sustaining brain contusions compared with those without macroscopic evidence of neural damage. Our understanding of the topic of concussion has come a long way since over the years, and we have now have clear guidelines for the assessment and management of concussion in sport which have been produced by the Concussion in Sport group and published widely, including in CJSM here.

Despite this, controversies still exist such as the possibility of the existence of the ‘second impact’ syndrome, differences in return-to-play protocols based on evidence, and the issue of subsequent morbidity and mortality associated with repeated episodes of concussion in earlier life.

The Concussion to Consequence webinar should help to shed light on some of these controversial issues.

Sign up here to join in.

(Illustration – Baron Guillaume Dupuytren October 5, 1777 – February 8, 1835, available here )

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