MRI for a muscle injury in a soccer player is right? Is ultrasound better? What does thermography add? In today's case study, we will see how all these imaging tests provide key information in the diagnostic process.

Muscle injury is considered one of the most frequent in the field of sport. This fact is especially relevant in sports that involve high-speed changes of direction, such as soccer, basketball, baseball, and American football. Epidemiological studies show that muscle injury in soccer accounts for more than 30% of all injuries. This implies a recurrence of between 1.8 and 2.7 muscle injuries per 1,000h of exposure, either training or competition (Green et al., 2020; Junge et al., 2006; Walden et al., 2005). Studies that show data separately, estimate that this musculature has an injury incidence of 0.5 per 1000h of training and between 3–4.1 per 1000h of competition (Ekstrand et al., 2016; Lempainen et al., 2015).

For a professional soccer team this represents about 12 muscle injuries per season. As a result, muscle injuries are equivalent to more than 300 days of absence from sports for the team in a season (Junge et al., 2006; Walden et al., 2005).

Case study: hamstring muscle injury in soccer

In this case study, we are going to take an in-depth look at the hamstring muscle injury of a soccer player, from three points of view:

• magnetic resonance imaging (MRI)
• ultrasound image
• thermography image

Each imaging test has its strengths and weaknesses. And what is more interesting: the combination of different technologies allows us to better understand the pathology, its extension, severity and implications. Let's discuss the pros and cons of these imaging tests.

Muscle injury through different imaging tests

Muscle injury is a type of musculoskeletal pathology that has been widely studied by different imaging tests. In addition to being very recurrent in acyclic sports, the quality of the diagnostic information depends on the intervention performed. Therefore, the decision made in cases of muscle injury should be based on diagnostic tests as accurately as possible.

Medical diagnosis is based mainly on the clinic and on two imaging tests: magnetic resonance imaging (MRI) and ultrasound. Both structurally describe this lesion, so that its location, severity, extent and the presence or absence of bleeding can be known (Ahmad et al., 2013; Pollock et al., 2016).

MRI is the modality chosen when greater precision is desired and it is considered the reference test, but at a much higher cost than ultrasound. The optimal time to perform MRI is between the first 24 and 72 hours, since this is when there are already appreciable signs that allow quantifying the severity of the injury (Kerkhoffs et al., 2012).

ultrasound , on the other hand, has the advantage of being much cheaper, but technically-dependent and, as with MRI, the most important ultrasound findings are the visualization of the hematoma, the discontinuity of the muscle fibers and the length, width and depth of the lesion (Ahmad et al., 2013; Svensson et al., 2018), but evidently with a lesser degree of precision.

It is estimated that when this injury is diagnosed, around 13% of cases are not identified with MRI (Ekstrand et al., 2016), which opens the doors to other forms of diagnosis that have better sensitivity and / or specificity results. In this way, infrared thermography, among other technologies, is postulated as a candidate to aid in the diagnosis of musculoskeletal pathologies, especially in muscle injuries.

The muscle injury in thermography

The current scientific literature does not shed much light on this and there are only a few articles that speak on the subject. Even, sometimes, this information is very heterogeneous and contradictory, so we will detail the publications that exist to date.

• The only systematic review with meta-analysis on thermographic diagnosis of musculoskeletal disorders (Sanchis-Sánchez et al., 2014) does not include a single article on muscle injury , like other reviews of the literature (Santos et al., 2014).
• In this same sense, in another review of the literature (Bandeira et al., 2014) it is argued that after the muscle injury there is a temperature rise , based on scientific literature. However, in said literature, either they do not talk about muscle injury (Nola et al., 2012) or they say that it is hyperthermic (Ríos et al., 2011), but they are based again on other articles (Niehof, 2007; Pichot, 2001; Ríos et al., 2011), none of which speaks at any time of muscle injury, so the quality of this conclusion is doubtful to say the least.
• In another of their works (Bandeira et al., 2012), they propose a method to detect muscle injury in soccer by correlating hyperthermic thermographic images with creatinkinase biomarkers. They establish a correlation between an increase in temperature and micro-injuries, something evident in a non-injury post-exercise recovery process, but not in a macroscopic muscle injury. Therefore, by not taking into account either the clinic or other imaging tests, it seems clear that muscle injury in soccer is not related to an increase in temperature. Similar studies have been replicated (de Andrade et al., 2017) and it appears that temperature increases with muscle damage. You can see it in detail here.
• In an observational study with correlation with medical diagnosis (Sillero-Quintana et al., 2015), muscle injuries are described as hyperthermic, with a Increase in temperature of 0.3º C with respect to its healthy contralateral, on a sample of n = 15.
• By contrast, works carried out in animals (Turner, 1991), more specifically in Racehorses show evidence of the hypothermic pattern associated with muscle injury , where the injured area is significantly colder than its contralateral.
• Lastly, recently, the first publications that speak of the hypothermic profile in muscle injury in humans, specifically in soccer (dos Santos Bunn et al., 2020; Fernández & del Estal, 2020), one of them awarded for its originality in this discovery for the scientific community.

The muscle injury in our case study

This soccer player is 34 years old and participates in the second division B of Spain. During his career as an athlete, he has only had a myotendinous injury in the right rectus femoris. He claims to have had other complaints, such as low back pain and a slight right ankle sprain, but nothing remarkable.

At the moment of his injury, the athlete was training with his team in a +48h-post-match training, of which he played 90 minutes. The specific action in which the injury occurred was in a heel strike, as detailed in the example in image 1.

Image 1. Heel strike by Carsten Arndt, from Blau -Weiß Günthersdorf vs TSV Leuna 1919 (preseason friendly).

He was immediately withdrawn from training and given the day off, as the clinic indicated a hamstring muscle injury, very common in the world of football.

The following morning, he was sent for an MRI , which confirmed a grade II fibrillar tear in the proximal region of the long head of the biceps femoris, with an extension of 3cm and significant bleeding. Details can be seen in image 2A.

48h after the injury, a transverse and longitudinal ultrasound was performed, which can be seen in image 2B. This test indicated an irregular hypoechoic area, where the muscle retraction space has been occupied by the hematoma, confirming the same length and diagnosis.

Finally, at 36h, a thermography was performed, which we will detail later.

Image 2. MRI, magnetic resonance image (A) and musculoskeletal ultrasound (B) of the soccer player
of the case study, 24 and 48 hours after the injury.

The muscle injury in soccer, seen with thermography: our case study

After showing the results of the lesion of our case study from the vision of the magnetic resonance image and the ultrasound, it is the turn of the themography. In image 3A we can see the thermogram of the posterior region of the legs. It is especially interesting to highlight the fact of an apparent loss of continuity in the representation of the temperature of the athlete's left posterior thigh. Furthermore, if we compare with the representation of the same region on the right side, we qualitatively detect an interesting hypothermic asymmetry. In image 3C we can see the player's own hand pointing to the exact area by asking where it hurts. The conclusion seems obvious, when relating the clinic to hypothermia in the same area, but we will still need the quantitative analysis. To do this, in image 3B we can observe the data of mean asymmetries, which return results below -0.3º C . The regions where the athlete reports pain appear in purple and the regions where an injury has been diagnosed are striped.

Image 3 . Thermogram of the lower posterior protocol, of the study subject's legs, showing a qualitatively significant hypothermic asymmetry on the left side of the posterior thigh (3A). Avatar of the anterior thermogram, showing quantitative results with hypothermia below -0.3º C in all regions of the posterior thigh (3B). Gesture of the athlete when asked to point to the region of pain (3C).

Summarizing the imaging tests in soccer muscle injury

To make its use more visible to aid in the diagnosis, we have adapted Table 1, based on the conclusions of the FC Barcelona Muscle Injury Clinical Practice Guide (Barcelona & Mèdics, 2009).

NameDegreeUltrasoundMagnetic ResonanceThermography*DOMS0Inconsistent signsInterstitial edema and increased local vascularizationInconsistent signsFibrillar micro-rupture and / or muscle elongationIMinimal discontinuity solutionIncrease in interstitial signalLocal signs of hypothermiaFibrillar ruptureIIClear muscle defectSignificant interstitial signal, focal muscle defectEvident cold island, which affects the regionMuscle tearIIIComplete muscle and / or tendon disruptionComplete muscle and / or tendon disruptionEvident cold island, which affects the entire body segmentTable 1: Adapted from the FC Barcelona Muscle Injury Clinical Practice Guide, adding the thermography column (Barcelona & Mèdics, 2009). * Statements based on clinical practice and not on scientific evidence, due to their low quality, scarcity and heterogeneity.

Conclusion

In conclusion, we would like to highlight the need for quality scientific evidence, confirming or denying the appearance of significant hypothermias in the region diagnosed with muscle injury. From our clinical practice, based on more than 10 years of experience confronting muscle injuries, it seems convenient to emphasize that the muscle injury has this typical behavior of temperature drop.

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