When an Olympic speed skater went off the track at the training facility in Colorado Springs, Colo., radiologists were able to remotely guide Olympic trainers through an ultrasound examination to immediately determine the extent of the skater's injury. They did the same for a weightlifter with an injured shoulder and a female wrestler who felt pain in her knee.

In two of the three cases, the radiologists determined that the injuries were not significant and the athletes returned to practice, while the third was sent for further evaluation.

Thanks to improvements in technology-such as portability-and a better understanding of the types of injuries to which athletes are prone, musculoskeletal imaging has a rapidly developing role in sports medicine. Rather than being transported to the hospital, more athletes are being assessed courtside at the NBA, poolside at the Olympics, or even trackside at NASCAR, to determine if they can get back in the game.

And while standard X-rays have long been used to assess fractured bones, dislocated joints and other sports-related injuries, computed tomography, nuclear medicine and MRI are joining sports medicine's on-field team. Even SPECT imaging, which is highly sensitive to such subtle bone injuries as stress fractures, is contributing to sports medicine.

But one modality-sonography-has been stealing more of the sports imaging spotlight as of late. A portable ultrasound machine provided by GE will soon be installed at the Detroit Tigers' Comerica Park for use by the Major League Baseball team's head athletic trainer. In the fall, the National Football League's Detroit Lions will also be provided with the service.

It's easy to see why. Ultrasound is safe, powerful, targeted and interactive. It is cheaper, faster and better tolerated than modalities like MRI. Whereas some patients cannot undergo MRI exams due either to absolute or relative contraindications, sonography is universally tolerated across a broad patient population.

Sonography is an effective method of imaging soft tissues and associated structures, it detects radiolucent foreign bodies and fluid collections, and it allows the accurate guidance of percutaneous therapeutic procedures at the same time the diagnostic exam is performed.¹ The operator's close interaction with the patient allows him to associate clinical features like tenderness directly with imaging appearances.

Of particular importance to sports imaging, another of sonography's key advantages is its relative quickness compared with an MRI or computed tomography study. Delays in scheduling are minimal, which is an advantage for patients who are traveling a long distance or who are in considerable discomfort.²

With portable ultrasound units, exams can be performed right on the playing field as soon as an injury occurs. This is especially critical for team physicians and sports medicine doctors, who often find themselves facing ethical challenges when making return-to-play decisions.

The November/December 2005 issue of the Clinical Journal of Sports Medicine was a special thematic issue providing updates on key topics related to return to play after athletic injuries.³ Athletes need full information on the risks of returning to play, yet doctors often have little high quality evidence on which to base these estimates, the journal editors write. Having ultrasound at their disposal could one day give athletic trainers additional insight when making those decisions.

"I think if people knew how to use it and knew its potential, ultrasound would be in much larger use right now for musculoskeletal imaging," said Levon Nazarian, MD, a radiologist at Thomas Jefferson University Hospital in Philadelphia.

Ultrasound as athletic trainer

Some physicians and athletic trainers have been able to use ultrasound more in athletes' medical care thanks to two initiatives by GE Healthcare. The first gave U.S. Olympic Committee medical staff and athletes at the 2006 Olympic Winter Games in Torino, Italy, access to portable ultrasound technology, and the second is a clinical research study focusing on musculoskeletal injury assessment involving the U.S. Olympic Women's Ice Hockey Team.

Independently performing and interpreting a diagnostic quality examination takes months to learn and years to master. However, Scott Dulchavsky, MD, PhD, chair of the department of surgery at Henry Ford Hospital in Detroit, adapted for athletic trainers an ultrasound training program he helped develop for astronauts who use the technology on the International Space Station. Dr. Dulchavsky's method cuts the 200 hours it normally takes to learn to operate ultrasound down to two to three hours a year, under supervision of a physician.

He and his team took their training methods to the three Olympic training facilities in Chula Vista, Calif., Colorado Springs, Colo., and Lake Placid, N.Y., where they instructed the trainers on the use of the equipment on high performance athletes.

"Working through both direct education, where we went to the sites, as well as some Web-enabled education, where we would remotely watch the exams that the trainers performed on the athletes, we were able to get all of these folks up to speed on portable ultrasound machines," he said.

The trainers then took Dr. Dulchavsky and his team to the Torino Games, where they helped guide trainers through exams on injured athletes. More than 200 ultrasound exams were performed on U.S. and international athletes. The U.S. Olympic Committee is collaborating with Dr. Dulchavsky's group to create research protocols involving Olympic athletes.

Angela Ruggiero, a defenseman for the U.S. Women's Ice Hockey Team, likes the idea of being able to assess injuries rinkside with ultrasound. The Olympic Games in Torino were the third for Ruggiero, who won a gold medal in Nagano in 1998 and a silver in Salt Lake City in 2002.

"In a situation like the Olympics where time is obviously of the essence, having this sort of capability was very instrumental for us," she said. "Knowing that in the background you have doctors that can read and diagnose you right on the spot was comforting."

Not only did Ruggiero and her teammates have ultrasound equipment ready at rinkside during the Torino Games, but they also served as the subjects of a clinical research study. Led by Dr. Dulchavsky and Marnix van Holsbeeck, MD, also of Henry Ford Health System, the study centered on improving the speed and efficiency of shoulder and knee injury diagnoses.

Over the course of a year, the researchers used a lightweight, portable ultrasound system to take healthy baseline scans of the women's ice hockey team to see whether the baseline scans would help determine the extent of future sports injuries with greater speed and accuracy.

"Should they have any injuries during the game, we would have a good baseline for comparison to determine whether they could continue playing or not," Dr. Dulchavsky said. "It was interesting to see the number of injuries that you could already see in this high-performing population, some of which they were unaware of."

The results of the study will be published in the next couple of months, according to Dr. Dulchavsky.

Ruggiero said the baseline scans provide advantages for someone like her who has a pre-existing shoulder injury.

"They could see from scar tissue that I had a pre-existing injury," Ruggiero said. "So if I were to re-injure my shoulder, they could see the new injury on top of that, as opposed to seeing the whole thing as one. Then I can have someone within five minutes tell me if I can get back in the game by tomorrow or if I can get back into the game that day."

Ruggiero said she also likes the ultrasound because it's non-invasive and can be performed while she's traveling with the team.

"Some people don't like having to commit the time to go into the hospital," she said. "And if you're traveling abroad with the team, you're going to foreign doctors with foreign machines and you don't know how quickly you're going to get the results back. This is obviously huge because with the ultrasound you can scan it, send it in real time and get everything back on the spot."

Ultrasound as intervention

For athletes who find themselves sidelined by either acute or chronic injuries, the next course of action is to consider their treatment options. Many injuries can be handled conservatively, whereas others may need immediate surgical attention.

However, patients who have failed conservative management may still have a Hail Mary in the form of ultrasound-guided percutaneous intervention. Therapeutic injections of corticosteroid and local anesthetic can be performed under ultrasound guidance for a wide range of symptomatic conditions, such as tendinitis, arthritis and bursitis. Real-time ultrasound can monitor injection to make sure the medication reaches its intended target. All procedures are performed with aseptic technique and local anesthetic.

Take an athlete with tennis elbow, for example. A radiologist would use ultrasound to first diagnose the problem.

"So if the patient has pain in the elbow, we want to put the ultrasound down and make sure there is scar tissue in the tendon and confirm the diagnosis of the tendon abnormality," Dr. Nazarian said.

After administering local anesthesia, the radiologist would then use ultrasound to guide a needle into the tendon to break up scar tissue and/or calcium deposits. Traumatizing the tendon with the tip of the needle encourages the body to develop a healing response.

"The healing response, which takes several weeks to really develop, is what eventually causes the tendon to heal," Dr. Nazarian said.

Ultrasound-guided aspiration can be performed for symptomatic ganglion cysts, liquefying hematomas, and Baker's cysts. In tenosynovitis, the injection is instilled directly into the sheath. For tendons without sheaths, such as the Achilles, injections are directed into the hyperechoic paratenon. Calcific tendonitis can be treated using 18-22 gauge needles, a procedure best documented for the rotator cuff.

Patients with chronic repetitive injuries that do not heal with the standard treatments of rest, ice, stretching, physical therapy, bracing, splinting and cortisone injections would be good candidates for the ultrasound intervention.

"It's very important to select the type of patient that will respond to this," Dr. Nazarian said. "This is not a treatment for a large, full thickness tear. What this is more designed for are patients with these chronic conditions like tennis elbow or golfer's elbow, where it's not a true rupture of the tendon, but rather the tendon degenerates and gets scar tissue and calcium in it. So although there may be little partial tears within the degenerated tendon, the main process is the degeneration."

Although the healing process begins within hours, the patient will start noticing it in about six to eight weeks, and will be able to resume normal activities after three months.

With increasing emphasis on minimally invasive surgical techniques, ultrasound-guided percutaneous interventions should become increasingly popular for the treatment of sports injuries, Dr. Nazarian said. For the moment, though, musculoskeletal ultrasound isn't commonly used in the United States, for a variety of reasons.

"Economics plays into it, the fact that people are very reliant on MRI plays into it, the fact that many people are insecure about their ultrasound abilities to begin with plays into it," he said. "Those are the hurdles that we have to overcome if we're going to make ultrasound a primary tool for guiding minimally invasive surgery.

"People are going to have to dedicate themselves to learning the imaging techniques because only after you learn the imaging techniques can you take the next step and guide therapies," he concluded.

References:

1. Orchard, JW, Read, JW and Anderson IF. The use of diagnostic imaging in sports medicine. The Medical Journal of Australia. 2005;183(9):482-486.

2. Sofka CM. Ultrasound in sports medicine. Seminars in Musculoskeletal Radiology. 2004 Mar;8(1):17-27.

3. Best, TM and Brolinson, PG. Return to play: The sideline dilemma. Clinical Journal of Sport Medicine. 2005 Nov;15(6):403-404.