MEDICAL CENTRES AND SCANS Lúnasa 2013 MEDICAL, SCIENTIFIC AND WELFARE COMMITTEE INTRODUCTION Technology is a critical component of modern day sports medicine. Whilst providing a cutting edge in terms of accurate diagnosis, it also raises issues such as cost, accuracy of interpretation and unnecessary use. The Medical, Scientific and Welfare Committee of the GAA appreciates the demands on team managers, team doctors and other support personnel regarding access to hightech medicine. The purpose of this document is to give GAA club members and interested stakeholders an understanding of the best practice guidelines set by the Association in terms of using medical centres and getting scans. KEY POINTS Some scans are inappropriately used and the wrong type of scans ordered in many instances A scan is secondary in the diagnostic process to history and clinical assessment of an injury and is not an essential part of treatment The history and examination should be done by an experienced doctor with an interest in musculoskeletal problems A team doctor should then decide on whether a player needs a scan The cost of MRI scans is approximately 200 It is imperative to note that a scan is secondary in the diagnostic process to history and clinical assessment of an injury and is not an essential part of treatment. Some scans are inappropriately used and the wrong type of scans ordered in many instances. This document primarily covers the scenario of an injury that does not require obvious emergency assessment and probable hospital Page 1 of 5
admission i.e. long bone fracture, shoulder dislocation etc In these cases the history and examination still remains the corner stone of diagnosis. This should be done by an experienced doctor with an interest in musculoskeletal problems. It does not need to be done by a surgeon or formal sports physician. There are many able doctors providing this service. Often a wait and see view can be taken were early assessment is not possible due to pain/swelling. Further examination of these patients should be scheduled with a suitable doctor rather than letting them drift off to rehabilitation programmes. WHAT MEDICAL CENTRES ARE AVAILABLE? There are a number of quality scan centres and skeletal radiologists nationwide therefore the Association no longer maintains a directory in this regard. The best practice recommended by the Medical, Scientific and Welfare Committee of the GAA is that a team doctor makes the decision about the medical centre to which a player should be sent. WHEN SHOULD I VISIT A MEDICAL CENTRE? Players injured as a consequence of exercise or sport should attend medical practitioners in diverse circumstances, urgency of assessment of the full impact of the injury varies across the spectrum from a serious injury to one in which a chronic condition can be evaluated. Hutson & Speed (2011) The primary requirement is the establishment of an accurate diagnosis; it is recommended that a club doctor decides on whether a player should be sent to a medical centre or not. A common scenario is a classic non-contact pivoting knee injury with inability to play on associated with significant effusion. A patient presents to local emergency room, has an X-ray (usually normal) and is put on crutches and sent for rehabilitation. He/she goes back to sport and develops recurrent knee instability, back to rehab, back to sport etc The player eventually finds his/her way to a doctor or physio that makes the correct diagnosis. If patients could avoid the A/E and be examined at a pre-determined time point in the future it would enhance player welfare and also lead to the more appropriate use of scans. WHAT IS A MRI SCAN? Page 2 of 5
Magnetic Resonance Imaging (MRI) is a technique that produces cross-sectional images of a patient s body, using magnetism and radio waves (British Medical Journal, 2011). It is a noninvasive way for your doctor to examine your organs, tissues and skeletal system. The images which a MRI scanner takes are very detailed therefore; it can often show things that aren t shown on an X-ray or in other tests such as an ultrasound. WHEN IS A MRI SCAN REQUIRED? Generally, MRI scans are done in cases where simpler tests will not give enough information for the doctors to form an accurate diagnosis. You may have an MRI scan to find out the cause of symptoms such as pain, joint or muscle stiffness, swelling or weight loss. There are a diverse range of clinical indicators for when a MRI scan is required. In the matter of shoulder injuries, often an MRI Arthrogram is a more appropriate exam negating the need for a plain MRI. If a patient has a long term shoulder complaint that is not settling with rehab an examination is advocated by someone experienced in shoulder pathology before ordering any scans. In summary, following any injury, if accurate diagnosis is not possible then the player should be reexamined at a different time point after RICE and early rehab prior to the ordering of any scans. It is important not to let players get in to a definitive rehabilitation programme without a reasonably thought out diagnosis. WHAT ARE THE RISKS OF THE MRI SCAN? The presence of metal in your body may be a safety hazard or affect a portion of the MRI image. Technologists should be informed if you have any metal or electronic devices in your body, such as: Metallic joint prostheses Artificial heart valves An implantable heart defibrillator A pacemaker Metal clips to prevent aneurysms from leaking Cochlear implants Any other type of metal fragment WHAT ARE THE ALTERNATIVES? Page 3 of 5
Other investigations that produce images of the inside of your body include x-rays, ultrasounds and computerised tomography (CT) scans. To ascertain the most appropriate, a player should consult with their doctor. WHAT IS THE APPROXIMATE COST OF TREATMENT? The cost of treatment is dependent on the injury which has been sustained by the player; however, a MRI scan currently costs as low as 200. It is recommended that Clubs and Counties try to come to some arrangement with an appropriate skeletal radiologist or scan centre. WHO COVERS THE COST OF MEDICAL TREATMENT? An MRI Scan/X-Ray request form from a medical centre must be completed and sent to the GAA immediately, the player must present this form on arrival to their medical centre The player must pay the fee and claim reimbursement through the GAA Player Injury scheme, subject to the rules of the scheme If the player has private medical insurance (e.g. VHI, Quinn Healthcare) a claim must be made with their medical provider. Otherwise unrecoverable medical expenses are covered up to a maximum of 4,500 (This benefit includes cover for MRI Scans up to a limit of 300 per scan and Post-Operative treatment up to a limit of 320. A maximum benefit of 40 per any one medical treatment applies). The first 100 of each and every claim is excluded For more information, visit http://www.willis.com/sites/ireland/gaa/is_benefits.htm LIST OF REFERENCES Mayo Clinic, 2013. MRI. [ONLINE] Available at: http://www.mayoclinic.com/health/mri/my00227. [Accessed 12 April 2013]. Hutson, M. & Speed, C. (2011) Sports Injuries. Oxford University Press. Oxford. Berger, A. (2002) Magnetic resonance imaging: How does it work? British Medical Journal. 324: 35. Page 4 of 5
Willis (2013). GAA INJURY SCHEME. [ONLINE] Available at: http://www.willis.com/sites/ireland/gaa/is_benefits.htm. [Accessed 12/4/2013] ACKNOWLEDGEMENTS Sincere thanks to Mr. Maurice F. Neligan MB, FRCSI (Orth) for reviewing this document and for his helpful comments. All correspondence should be directed to the Secretary of the Medical, Scientific and Welfare Committee T: (0) 1 865 8685, E: playerwelfare@gaa.ie Page 5 of 5