A SUPPLEMENT TO THE SEPTEMBER 2000 ISSUE OF DIAGNOSTIC IMAGING
 

September 2000

Scintigraphy detects weight-lifting injuries

Acute and chronic injuries increase with strength training; imaging children requires special care

By Hans Van Der Wall, Ph.D.

As the level of competitive sports increases in all age groups, weight training has become a standard part of the fitness regimen for both amateurs and professionals. Inevitably, a wide range of injuries to soft tissues, ligaments, and bones has resulted. Scintigraphy has the potential to detect these injuries, as well as many clinically unsuspected abnormalities. Scintigraphic studies also yield prognostic information that can be useful in directing treatment. But special care must be taken with acquisition techniques and reporting, especially with children.

In casual contact sports as well as noncontact swimming, golf, and tennis, there is little supervision and high potential for injury. The skeletons of children and adolescents are immature, and serious growth disturbance can follow injury to the epiphyseal growth plate complex.1

The injuries may be classified into acute or chronic overuse injuries. Acute injuries include fractures, bone bruising, avulsion, or soft-tissue injuries. Chronic injuries include stress fractures, “splints,” enthesopathies or tendon injuries, and joint damage. In weight training, many of these injuries result from either a rapid and unaccustomed increase in the load lifted or the accidental loss of control of the weights, usually free weights.

Scintigraphy with the diphosphonate bone agents is a functional imaging technique that detects altered stresses in bone or soft tissues before manifestation of secondary structural changes that show up with such anatomical imaging techniques as x-ray or CT. It not only allows early detection of symptomatic injuries but often contains prognostic information and may reveal unexpected pathology.2,3 Often, it offers information that complements MR findings, especially in areas like the knee.4

Upper Limbs

Injuries of the upper limbs are most common in bodybuilders and power lifters. A review of 358 bodybuilders and 60 power lifters showed major shoulder and elbow injuries in 40% and muscular injuries in 84%.5 In this sample and in other cases, the injury rate increases with free-weight lifting compared with fixed-weight machines.6 The most commonly reported injuries in the upper limb, as revealed by scintigraphy,7,8 are tendinitis at the wrist, epicondylitis and triceps/biceps insertion injury in the elbow (Figure 1), rotator-cuff disease (Figure 2), and isolated supraspinatus and long head of biceps tendinitis in the shoulder.

Occult fractures of the scaphoid, lunate, hamate, distal radius, olecranon, and radial head, as well as the clavicle and scapula, have been reported. Osteolysis of the clavicle (Figure 3) can be diagnosed with great sensitivity, as can post-traumatic degeneration of the sternoclavicular/acromioclavicular joints, wrist, and elbow. Muscle splints are readily apparent in the arms and forearms, as is muscle injury. See Figures 4 and 5.

Apart from osteolysis of the clavicle, weight-lifting injuries have no specific pattern and may occur anywhere in the upper limb. In sports that require throwing or swinging the arms, there are specific patterns of injury.9

Lower Limbs

Injuries of the lower limbs and spine are common in adolescents doing weight training. One study found a rate of 7.6% in 354 high school students, with a preponderance of knee and spinal injuries.10,11 The mechanisms of such injuries range from enthesopathy and avulsion injuries of the pelvis to bursitis, muscle injury, splints, and tendinitis. Ligaments are injured in the knees and ankles, and stress fractures occur in the hip, tibia, and metatarsals. While there are no large scintigraphic studies dealing specifically with weight-lifting injuries in the lower limb, these are stereotypic injuries that also occur in other sports, and the patterns are easily recognized.3,12,13

Avulsion injuries are common in the adolescent athlete and may be quite disabling, particularly in the pelvis,14,15 with weight-lifting squats implicated. Bone scintigraphy offers a sensitive diagnosis as well as prognostic information. The degree of separation of the apophyses correlates with the time to healing and may be used to direct therapy. An example of avulsion of the apophysis of the ischial tuberosity is shown in Figure 6.

Overuse injuries of muscle may lead to necrosis or ischemia and pain. There are numerous reports of uptake of the bone-scanning agents in damaged or ischemic muscle, due either to overuse or to compartment syndrome. Weight-lifting squats have been implicated in this form of muscle damage, specifically with regard to the adductor muscles of the thighs.

Stress fractures in the lower limbs rarely result from weight training, with few reports of fractures of the pelvis, hip, or tibia. This may reflect the different pattern of stress/cyclical overloading from that which occurs, for example, in long-distance running.

With careful attention, many abnormalities in the knee and ankle can be accurately diagnosed using single-photon emission computed tomography (SPECT), including internal derangements of the knees such as avulsions/tears of the cruciate and collateral ligaments and meniscus, bone bruising, and fractures.16 The technique can also help identify injuries in the ankle, particularly ligament avulsions and talar dome fractures.

High-quality images with a good count density may be obtained with gamma cameras that have either two or three heads and simultaneously acquire counts from different positions. This has helped increase both the throughput and quality of images in the last 10 years.

The Back

Back injuries from weight training are more common in young athletes,11 with defects of the pars interarticularis the most common cause of low back pain in children and adolescents.17 Weight lifting and other sports that load the back in hyperextension are believed to cause microfractures, usually in the isthmus of the pars interarticularis of L4 or L5. A pseudoarthrosis afflicts some, leading to the transference of strain to the contralateral pars interarticularis, which also eventually fractures. The bilateral fractures then predispose the patient to spondylolisthesis. This mechanism, rather than a congenital abnormality, is thought to be the major cause of spondylolysis.17 These injuries are likely carried into adulthood and may be reactivated by sports such as weight lifting.

The incidence of radiological pars interarticularis defects is reportedly as high as 30% in elite child athletes.17 Bone scintigraphy is highly accurate in detecting such lesions, and it has a high negative predictive value for spondylolysis or spondylolisthesis as the etiology of back pain, regardless of whether a radiographic abnormality is present.18

Imaging of back injuries has been problematic for scintigraphic studies, due to the overlap of the many structures in the vertebral body. Lesion detection with SPECT is much better than with the traditional two-dimensional planar studies (Figure 7). With special image reconstruction techniques, one can specifically distinguish zygoapophyseal joint disease and Scheuermann’s disease from fractures of the pars interarticularis and compression fractures of the vertebral body. Zygoapophyseal joint disease is a common finding in virtually all sports that involve truncal rotation, including several weight-training routines. Scheuermann’s disease is usually inactive on bone scintigraphy or may rarely demonstrate vertebral body endplate activity.

Children

Scintigraphic imaging in children requires great care in acquiring studies as well as a sound knowledge of the temporal changes in the normal scan appearances with age. Radioactive urine contamination of the pelvis and lower limbs must be carefully excluded and a whole-body image acquired if there is any suspicion of occult underlying pathology. Since the growth plate is a discoid structure, the limbs must be positioned with the growth plate and the contralateral limb tangential to the camera face, to allow comparison for asymmetry (Figure 8).

Injuries to the growth plate and epiphysis can have serious long-term complications, and weight training is one of the sports associated with them.19 One must recognize the scan patterns of entities such as osteochondritis dessicans, osteochondral fractures, and fractures through the growth plate.20 There must also be an awareness of coincidental causes of symptoms, including primary bone and cartilage tumors, metastatic disease, infection, Perthes disease, and slipped capital femoral epiphysis—all recognizable by specific scintigraphic patterns. Weight training by individuals with such underlying pathology can be disastrous.

References

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  9. Sinha AK, Kaeding CC, Wadley GM. Upper extremity stress fractures in athletes: clinical features of 44 cases. Clin J Sport Med 1999;9:199-202.
  10. Risser WL. Weight-training injuries in children and adolescents. Am Family Phys 1991;44:2104-2108.
  11. Risser WL, Risser JM, Preston, D. Weight-training injuries in adolescents. Am J Dis Child 1990;144:1015-1017.
  12. Fernandez-Ulloa M, Klostermeier TT, Lancaster, KT. Orthopaedic nuclear medicine: the pelvis and hip. Semin Nucl Med 1998;28:25-40.
  13. Kanstrup IL. Bone scintigraphy in sports medicine: a review. Scand J Med Science Sports 1997;7:322-330.
  14. Kujala UM, Orava S, Karpakka J, et al. Ischial tuberosity apophysitis and avulsion among athletes. Int J Sports Med 1997;18:149-155.
  15. Sundar M, Carty H. Avulsion fractures of the pelvis in children: a report of 32 fractures and their outcome. Skeletal Radiol 1994;23:85-90.
  16. Murray IPC, Dixon J, Kohan L. SPECT for acute knee pain. Clin Nucl Med 1990;15:828-840.
  17. Hollingworth P. Back pain in children. Brit J Rheumatol 1996;35:1022-1028.
  18. Mandell GA, Harcke HT. Scintigraphy of spinal disorders in adolescents. Skeletal Radiol 1993;22:393-401.
  19. Lipp EJ. Athletic physeal injury in children and adolescents. Orthop Nursing 1998;17:17-22.
  20. Siffert RS. The effect of trauma to the epiphysis and growth plate. Skeletal Radiol 1977;2:21-30.

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