Fellrunners are a passionate group who know everything about the fells, extreme weather and rough terrain, but probably not a lot about the world of imaging. Hopefully this article will give an insight and understanding into the scans that are available, and when you should consider further investigations.
I am very pleased to have written this article with Denise Park, World renowned physiotherapist accredited from both World Mountain Running association and Fell Runner's Association, who I have worked closely with since 2007. We share a passion for digging that bit deeper to get to the bottom of someone’s symptoms which can be obscure and unusual in fell running, aiming for an accurate diagnosis that helps in deciding the most appropriate intervention - and hopefully a speedier return to running.
Running is a fine balance between achieving your objectives and avoiding injuries, but unfortunately injuries are part and parcel of fell running. Injuries experienced can mainly be divided into those resulting from trauma such as twisting an ankle, falling or tripping, and those that occur over a period of time due to the damage or increased stress of various body structures, which are referred to as ‘overuse’ injuries. Research has shown that 49% of fell running injuries are caused by overuse or a change in training, resulting in injuries such as Achilles tendinosis in tendons (see Figure 1), to shin splints or stress fractures in the bones (see Figures 2 and 3). These overuse injuries are more common in novices to running as the structures have not had time to adapt to the new strains and stresses, and in the older age group.
Why do fellrunners need to know about scans?
Injuries generally present as pain or restriction of movement or giving way of a joint. Assessment by a GP or physiotherapist results in a clinical diagnosis, but imaging helps us to look into the joint or the soft tissues to confirm a clinical diagnosis - or throw light onto a more complex presentation (see Gary Mason’s story). Once the diagnosis is known or confirmed by imaging, appropriate treatment and rehabilitation can be planned.
As I discussed in my last article, pain on the inner aspect of the knee is often diagnosed as osteoarthritis in the clinical setting, especially when it is known you are a fellrunner. As we now know from research, running appears to delay the onset of osteoarthritis in joints, so instead of accepting a diagnosis of ‘wear and tear’, it may be necessary to have further investigations to determine the true cause of the pain. Other possibilities are a stress fracture, a tear in the cartilage (the medial meniscus) a sprain to the ligament on the inside of the knee (the medial collateral ligament) or damage to the quadriceps expansion which is around the kneecap (patella) and is a very common fell running injury. Given it is often difficult to identify this particular injury on a scan image – the scan is still useful to exclude any other possible underlying causes of the pain - especially if the injury does not respond to a course of appropriate physiotherapy treatment.
What is ‘imaging’ and what scans are available?
Imaging is being able to see inside the body structure with a scan. (see Box 1) Many of you will be familiar with x-ray, which is a form of imaging using ionising radiation. This is a basic form of imaging which shows the bones very well - but not the soft tissues. It is very useful when there is an acute injury to identify a fracture or broken bone. However, stress fractures, which are slow fractures of the bone structure due to stress, are not always identifiable on x-ray (see Figure 3) in the early stages and may take up to 6 weeks to be visible.
Given most fell running injuries are soft tissue injuries rather than bone injuries, x-rays may not be beneficial. The scans that are useful for these injuries are ultrasound and MRI scans.
An ultrasound scanuses sound waves to provide imaging of soft tissue structures, such as a tendon (see Figure 1). It is very useful to assess soft tissue structures which are just below the skin (superficial) and to do guided injections so the Radiologist can see exactly where the needle is situated in relation to the injury. However, an ultrasound scan is very dependent on the expertise of the examiner and cannot assess the bones.
An MRI (magnetic resonance image) scanassesses both the bones and the soft tissues. Magnetic resonance imaging uses a magnetic force to form images of the body structures. This allows excellent images of the body structure in 3-dimensions and is effectively looking inside without having to do surgery (see Figure 2).
Due to the magnetic force used, it can be dangerous to scan someone who has a cardiac pacemaker, stents in arteries or aneurysmal clips, so if someone has any of these devices, an alternative scan might have to be considered. However, some people with cardiac pacemakers are now able to have MRI scans.
It must also be remembered that MRI’s often throw up false positives. These are things that might be seen on the scan – but which are not the cause of the pain. MRI scans of knees of 51-89 year old patients identified abnormal findings in 87% - although none had any knee pain (Guermazi et al, 2012) and disc degeneration was seen in 79% of scans on patients who were not experiencing back pain (Brinjiki et al 2015). This highlights the importance of good clinical assessment and correlation of the imaging with the radiologist.
A CT (computed tomography) scanuses x rays to provide a 3-dimensional image of the body part. In the context of runners and the musculoskeletal system, it is useful for bony structures but not for the soft tissues. It is, however, very useful for assessment of the head, chest and abdominal viscera, but because it uses x-rays there is still a risk of radiation.
A bone scanuses a radioactive isotope which accumulates at the site of a fracture or an infection in the body. This is then seen as an ‘active’ site on the bone scan. The bone scan can be used for assessment of stress fractures but in most cases, has been superseded by MRI scans as bone scans also carry the risks of radiation.
When do you need imaging?
Imaging is particularly beneficial in the following scenarios.
1. In many cases, your GP, physiotherapist or sports therapist will diagnose your injury and with appropriate therapy, it will resolve. However, if the symptoms do not resolve, or get worse despite physiotherapy, imaging would be appropriate to understand the underlying cause and the degree or extent of the problem.
2. If the cause of the symptoms is unclearon clinical examination. If a fellrunner presents with heel pain, it may not be clear whether it is plantar fasciitis, a stress fracture of the heel bone (the calcaneum), tendinopathy of the tendons which flex the toes (flexor hallucis longus or flexor digitorum longus), the Achilles tendon or another condition called tarsal tunnel syndrome.
3. When an injury has been diagnosed clinically, you may need confirmation of the diagnosisto help with subsequent management. If there is a meniscal tear it might be necessary to confirm the extent of the tear to determine if surgery is necessary.
4. A scan can confirm but also exclude an injury, so the correct rehabilitation therapy can be continued. This is particularly important in stress injuries of the bones. It is imperative to diagnose any stress reaction at an early stage before it progresses to a full-blown fracture which will lead to a much longer period of rehabilitation and healing.
5. When rehabilitation doesn’t seem to be working, despite a scan, it is sometimes necessary to get a second opinion. Injuries are sometimes missed because the Radiologist looking at your images may not be fully aware of your symptoms, or may not be experienced or specialised enough–especially when your injury is unusual and is something that may be unique to off-road running. Several years ago, Victoria Wilkinson ruptured the tendon under her big toe whilst doing hill reps. There had only been 5 previous reported cases of this injury in the world which were in track runners and ballet dancers - but because of the forces involved in the push-off doing hill reps, it is an injury seen in fell runners. Luckily, it is usually damage to the tendon rather than a tendon rupture – but because it is unusual it can be missed.
What imaging is appropriate?
The various imaging modalities have their pros and cons.
On a simplistic and pragmatic basis, the choices are chiefly between ultrasound or MRI scan. Both are safe and do not carry the risk of ionising radiation.
MRI scan can investigate and assess both the bones and soft tissues whereas an ultrasound is useful in the assessment of superficial soft tissue structures but cannot assess the bones. As a rough rule of thumb, ultrasound is useful, when the source of pain can be pinpointed such as a tendon or a lump. MRI scan is useful when the source of pain is diffuse or not clear i.e. you have to place your palm or hand to indicate the site of the pain.
It is generally useful to have a discussion with a Radiologist who can help decide on the most appropriate scan.
My Story – Gary Mason
In 2019 I moved to a different running group in Morpeth Harriers and started training harder. I upped my mileage from about 45 miles per week to 60-65 per week with one week of 75 miles in preparation for Ennerdale later in the year. I also lost weight. The combination of these things meant I was running better than ever. Most weekends I would be racing and enjoyed the long hard fell races. I completed Ennerdale, The McWilliams challenge round in Northumberland and several other long, hard fell races for the first time, including the Teenager with Altitude and The Great Lakes races. Things were going really well, and I just wanted to make the most of it. I loved the racing and being out in the hills meeting various folk. I literally felt on top of the world!
In July, I started to experience an ache in the groin and put it down to training hard and running in general. As someone once told me - when you run you’ve always got something wrong with you! It didn’t really bother me too much, so I continued running. In September I got a PB at Ben Nevis and, because I have always done the Great North Run since I started running, ran it the next day. I had another great run and got another PB.
I did some other fell races in September, but the groin ache remained. It felt as though something wasn’t working properly in my hip/groin area when I started running, but as it seemed to wear off as I warmed up, I continued running.
In October, I did Manor Water fell race then Kielder marathon the following day, getting yet another PB. At the finish my groin was really painful and I struggled to walk back to the car. I rested most of the week and did the fell relays the following weekend. The groin was sore during the run, but as it was now uncomfortable even on walking, I thought I should see a local physio.
The physio advised a few weeks rest, but as the pain didn’t ease I contacted him for further advice. Unfortunately, he didn’t return my call.
Over the next few months I saw a nurse practitioner, had a telephone assessment with the Joint Musculoskeletal and Pain Service (JMAPS), and was given exercises by an NHS physio who said I had an inflamed hip capsule and some tendinopathy. I repeatedly asked if I could be referred for an MRI scan because I thought I might have a stress fracture, but was told every time that it was not possible.
I did the exercises diligently, but the pain in my hip and groin was getting worse rather than improving and to add to it, my follow-up NHS physio appointment was cancelled The situation had now deteriorated to the stage where the pain was causing me to limp whilst walking, so I completely rested from all exercise. Even the rest did not help this time so I went back to the GP. He reluctantly referred me for an x-ray which reported I had moderate arthritis in both hips. This surprised me as my left hip had clicked and clunked for a number of years, but my right hip had never caused me any problems.
Given I now had a diagnosis of arthritis, I was told I no longer needed an MRI scan but instead would be referred to an Orthopaedic Consultant. Cortisone injections, hip resurfacing and a hip replacement were mentioned – all which came as quite a shock to me.
Feeling a bit dejected and rather frustrated, I posted a message on the Fellrunners group on Facebook asking if anyone else had similar problems. Straight away, I got a message from Denise advising me that if I really wanted an MRI scan, she could refer me privately to Professor Khan via a company called Scan-doctor (www.scan-doctor.co.uk). Having spent months of repeatedly asking for an MRI, I decided to go ahead as I desperately wanted to know what was wrong for my own peace of mind.
Denise needed a detailed history of my history and symptoms which enabled her to refer me to Professor Khan to have the most appropriate MRI scan. Within a couple of weeks, I had the MRI scan close to where I live, and the images were sent to Professor Khan.
A few days later, Denise contacted me to explain in plain English what the MRI had revealed. I had multiple things including osteoarthritis of the hip joints- but the main source of the problem appeared to be partially fused sacroiliac joints (see Figure 4). This was worse on the left side and it was this that had probably caused the wear in my hips – but more importantly – these findings suggested I possibly had a type of inflammatory arthritis called ankylosing spondylitis.
Denise explained that with the right management and medication this condition could be controlled, plus she knew of other fellrunners with the condition who were still running and racing which was a relief to hear.
Given the findings, I returned to my GP who then added that I had other symptoms also suggestive of this condition, so he referred me to a Rheumatology Consultant.
Even though I was initially shocked at the scan report, I now feel more informed - and feel that someone has finally listened to me and I have a plan moving forward. The exercises I have done over the years have probably been beneficial if I have this condition, but the scan findings have hopefully got to the bottom of my symptoms. I was not aware that it was possible to request an MRI scan privately, so I am so pleased Denise responded to my Facebook message. I cannot thank them enough, and I really hope that I am now on the right road to recovery.
The Reality of Imaging and Fellrunning Injuries
Unfortunately, most fellrunning injuries are not high priority within the NHS system, which is already stretched beyond breaking point. If you fall and have a serious injury – the NHS is everything you would hope for - but knee pain whilst running off Coniston really isn’t seen as a high priority. I appreciate you have every right to battle through the NHS system, but at the end of the day it is only you who will suffer physically and mentally whilst you cannot run.
Thankfully it is now possible to obtain MRI scans privately and there are several companies offering this facility. Prices vary, but it is currently possible to have an MRI scan with a report interpreting the images for less than £300. It is recommended that a health professional such as a physiotherapist or GP refers you for a scan given the referral letter can provide crucial information to decide on the most appropriate scan and to minimise any false positives, although this isn’t essential.
Perhaps it is time for you to take responsibility for the management of your injury and hope this article has given you an overview of imaging, and how it can help next time you have that niggle that does not go away!
Box 1.
Imaging Modality | X ray | Ultrasound | MRI | CT | Nuclear medicine |
briefly | Uses x rays to image | Using soundwave to image | Using magnetic force to image | Uses x rays but to form 3D images | Uses radioactive isotopes to image |
Pros | simple | Simple. Useful for superficial structures. Helps with guided injections. | Most useful for imaging both bones and soft tissues. No radiation risk. | 3D images of bones. Useful in fractures or overlapping bones in wrist/feet. | It is functional and assesses stress fracture. |
cons | Only useful for bones. Not useful for soft tissues. Radiation risk. | Not useful for deep structures or bones. User dependent. | Contraindicated in pacemaker, stents etc. Slightly expensive. | Soft tissue is poorly assessed. Significant Radiation risk. | Radiation risk. The anatomy is well delineated. |
Figure 1. Ultrasound scan of the Achilles tendon in a fellrunner, showing the thickening of the Achilles tendon due to tendinopathy (thin long arrows) and of the surrounding lining, referred to as paratenon (block arrow).
Figure 2. MR of knee in a fellrunner, who was extending the distance run. Linear dark irregular stress fracture (thin arrow) is seen in the proximal tibia with surrounding bright bone swelling (oedema) due to bruising.
Figure
3. X ray of the knee of the fellrunner in Figure 2, which appears normal, and the fracture cannot be identified.
Figure 4. MR scan through the sacroiliac joints, which shows partial fusion of left sacroiliac joint (see thick arrow) compared to unfused right sacroiliac joint (thin
arrow). This is suggestive of inflammatory arthritis.
Professor Shah Khan is an accredited Musculoskeletal Radiologist and has earned national and international recognition for his contribution to radiology and his dedication to patients. He is the only British Musculoskeletal Radiologist to be awarded the highly prestigious European Society of Skeletal Radiologists Award and the Bronze award by the national Advisory Committee for Clinical Excellence Award (ACCEA) for excellence in radiology in 2020. He is incredibly skilled in assessing musculoskeletal injuries and, after working so closely with Denise for over 12 years, has a deep understanding of fell running injuries.
He regularly publishes and lectures in International/National meetings and is on the faculty of Sports Injuries MSc course in UCLan and Musculoskeletal Ultrasound MSc course in University of Cumbria.
For further information, visit his website www.scan-doctor.co.uk or email info@scan-doctor.co.uk.
Denise is a Musculoskeletal Chartered Physiotherapist based in Clitheroe, Lancashire. She started working with fell runners in 1989 and was physio to the England Mountain Running Team for over 10 years. She has worked at many international fell and mountain races, and in 2008 was accredited by the World Mountain Running Association for her work with elite mountain runners from around the world. In 2011 she was asked to write a chapter in the medical textbook ‘Adventure and Extreme Sport’s Injuries’, when she was recognised as the world’s leading expert in fell and mountain running injuries.