The Utility of MRI in Injured Athletes' Return To Play
Two new papers discuss whether MRI can effectively determine when an athlete should return to the sport after injury
A key component of clinical sports medicine involves giving advice to an injured athlete about when it's safe to resume playing the sport. In order to make a return-to-play decision, the physician must evaluate the health status of the athlete based on history, symptoms, signs, and laboratory as well as functional testing.
In particular, the use of imaging techniques such as plain radiographs, MRI, CT, bone scans and ultrasound may give physicians a better look into how healing is progressing. But not all experts agree on the effectiveness of MRI in assessing injury recovery and return to play.
Two recently published papers demonstrate some of the disparity that exists among sports medicine doctors about how MRI factors into decision-making for different injuries. The first paper, published by an international team of authors in the journal Knee Surgery, Sports Traumatology, Arthroscopy in April, argues that MRI has limited value in predicting return to play after an acute hamstring muscle strain.
“While MRI has been proposed to be useful in determining the return to sport after a hamstring injury, we do not believe that there is any substantial evidence to support this,” said co-author Bruce Hamilton, the director of performance health at High Performance Sport New Zealand. “Imaging is not useful in helping to determine if someone is ready to return to play, and a large number of factors are involved in this.”
A number of researchers have proposed classification and grading systems for muscle injuries with the goal of assisting in the return-to-play decision. The Cohen MRI scoring system, created in 2011, claimed MRI scans could be used to accurately predict the severity of injury and games missed after hamstring injuries in professional football players.
Hamilton and his colleagues questioned the scoring system's results and decided to embark on their own study. They performed standardized clinical and MRI examinations on 139 male soccer players with acute onset posterior thigh pain within five days after injury. For each participant, the Cohen MRI score (0 to 16) and actual return-to-play duration were compared.
Overall, the authors concluded that the Cohen MRI scoring system has “no clinical value” for predicting how long it takes an athlete to return to the sport. Although athletes with a score of less than 10 had a significantly different average than those with a score of 10 or more, the large standard deviation eliminates any utility for decision-making, they found.
However, Hamilton doesn't claim that MRI has no utility at all within the world of sports medicine. The technique can indicate if there is a complete rupture of the proximal hamstring origin (i.e., a tendon injury), or register as negative for any obvious injury. But when it comes to MRI for predicting return to play, Hamilton hasn't seen any evidence of clinical relevance yet.
“Our group feel strongly that MRI is very useful in determining the nature of the injury, whether it is predominantly tendon or muscle involvement, which muscle specifically is involved in the hamstring complex,” said Hamilton. “This information, for the elite athlete, can be very important in determining the best approach to any intervention or rehabilitation.”
The second paper, a book chapter in Return to Play in Football: An Evidence-Based Approach, describes how MRI can help assess healing of anterior cruciate ligament (ACL) tears and graft maturation after surgical reconstruction. While MRI provides a noninvasive insight into the biomechanical properties of the graft, no studies had assessed the effectiveness of the technique in determining the optimum time for patients to return to play.
“These competitive athletes are always pushing the limits of their bodies in an attempt to return to play as early as possible, but no absolute criteria currently exist to determine readiness to return to football so as to diminish the risk of re-tear,” said Marcio Albers, a research fellow at the University of Pittsburgh Medical Center's Center for Sports Medicine. “This chapter was written with the intent to clarify how MRI may be another tool to aid in the decision-making of when one can safely return to play.”
The authors claim that MRI could not only be used as a tool to help track the healing process, but could also open the door for physicians to accomodate each treatment to a patient's unique anatomy and needs. Individualized anatomical ACL reconstruction, a new concept based on tailoring the surgery to the individual patient, uses MRI scans and other precise measurements to restore the ACL to replicate the original anatomy as closely as possible. Albers also believes rehabilitation and duration of return to play should be considered by physicians on a case-by-case basis.
“It is of ultimate importance to individualize the rehabilitation program and gradual return to sports activities for each patient,” said Albers. “There are still many unknown factors involved in determining when safe return to football should occur.”