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The epidemiology of MRI detected shoulder injuries in athletes participating in the Rio de Janeiro 2016… Murakami, Akira M; Kompel, Andrew J; Engebretsen, Lars; Li, Xinning; Forster, Bruce B; Crema, Michel D; Hayashi, Daichi; Jarraya, Mohamed; Roemer, Frank W; Guermazi, Ali Aug 17, 2018

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RESEARCH ARTICLE Open AccessThe epidemiology of MRI detectedshoulder injuries in athletes participating inthe Rio de Janeiro 2016 Summer OlympicsAkira M. Murakami1* , Andrew J. Kompel1, Lars Engebretsen2,3,4, Xinning Li5, Bruce B. Forster6, Michel D. Crema1,7,8,Daichi Hayashi1,9, Mohamed Jarraya1,10, Frank W. Roemer1,11 and Ali Guermazi1AbstractBackground: To use Magnetic Resonance Imaging (MRI) to characterize the severity, location, prevalence, anddemographics of shoulder injuries in athletes at the Rio de Janeiro 2016 Summer Olympic Games.Methods: This was a retrospective analysis of all routine shoulder MRIs obtained from the Olympic Village Polyclinicduring the Rio 2016 Summer Olympics. Imaging was performed on 1.5 T and 3 T MRI, and interpretation was centrallyperformed by a board-certified musculoskeletal radiologist. Images were assessed for tendon, muscle, bone, bursal,joint capsule, labral, and chondral abnormality.Results: A total of 11,274 athletes participated in the Games, of which 55 (5%) were referred for a routine shoulder MRI.Fifty-three (96%) had at least two abnormal findings. Seven (13%) had evidence of an acute or chronic anteriorshoulder dislocation. Forty-nine (89%) had a rotator cuff partial tear and / or tendinosis. Subacromial / subdeltoid bursitiswas present in 29 (40%). Thirty (55%) had a tear of the superior labrum anterior posterior (SLAP).Conclusion: Our study demonstrated a high prevalence of both acute and chronic shoulder injuries in the Olympicathletes receiving shoulder MRI. The high rates of bursal, rotator cuff, and labral pathology found in these patients impliesthat some degree of glenohumeral instability and impingement is occurring, likely due to fatigue and overuse of thedynamic stabilizers. Future studies are needed to better evaluate sport-specific trends of injury.Keywords: MRI, Olympics, Shoulder, InjuryBackgroundThe 2016 Rio de Janeiro Summer Olympic Games wereheld from August 5 to 21, 2016, bringing together11,274 elite athletes from 206 different countries and ateam of refugees. In this elite international competition,8% of athletes incurred at least one injury during partici-pation. Forty percent of these injuries resulted in loss ofcompetition for at least 1 day, and 20% of the injuries re-sulted in loss of competition for greater than 7 days [1, 2].Shoulder injuries constitute a small subset of all injur-ies at the Olympic Games, however the pain associatedwith even chronic conditions such as tendinosis canresult in significant pain symptoms [3]. The relative lackof osseous restraint within the glenohumeral joint allowsfor the mobility and flexibility required for high levelathletic performance. However, it also places a highphysical demand on the static and dynamic stabilizers ofthe shoulder, particularly in athletes at this level.Overuse injuries to the rotator cuff and shoulder gir-dle muscles as well as to the labrum, joint capsule,and cartilage can result in instability and impinge-ment of the joint, impeding performance [4].Shoulder pain and injury has been particularly welldocumented in sports with repetitive overhead motions[3, 5–8]. While the overhead throwing athlete in particu-lar seems most at risk, there are many Olympic sports inwhich similar demands are placed on the glenohumeraljoint. High level athletes in contact sports such as rugbyand American football can also sustain similar injuries* Correspondence: akira.murakami@bmc.org1Section of Musculoskeletal Imaging, Department of Radiology, BostonUniversity School of Medicine, FGH Building, 3rd Floor, 820 Harrison Ave.,Boston, MA 02118, USAFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Murakami et al. BMC Musculoskeletal Disorders  (2018) 19:296 https://doi.org/10.1186/s12891-018-2224-2even when overhead throwing motions are not inherentin their particular activity [9–11]. While various imagingmodalities have been used for diagnosis, magnetic reson-ance imaging (MRI) has been the established imagingmodality of choice in evaluating such conditions [4].The aim of our study is to use MRI to characterize theseverity, location, prevalence, and demographics of acuteand chronic shoulder injuries observed at the Rio deJaneiro 2016 Summer Olympic Games, in order to betteranticipate athlete diagnosis and care in future events ofan elite caliber.MethodsThis is a retrospective analysis of the patient informationfrom the International Olympic Commission (IOC) ath-lete database and imaging data from the RadiologicalInformation System (RIS) and Picture Archiving Com-munications System (PACS) of the Rio 2016 SummerOlympics. The earliest imaging was performed 6 daysprior to the opening ceremonies, and the last study wasacquired 1 day after the closing ceremony. The assignedathlete accreditation number was used to query the IOCdatabase for demographic information, which includedage, gender, nationality, and sport. All information wastreated with strict confidentiality, and our medical data-base was de-identified. The study was approved by themedical research ethics committee of the South-EasternNorway Regional Health Authority (2011/388) and wasexempt from Ethics Committee approval. Informed writ-ten consent was waived since all epidemiological datawas anonymized and unidentifiable. The use of anon-ymized imaging and demographic data for publicationwas approved by the IOC. An additional InstitutionReview Board (IRB) was obtained from Boston University(#H-36593). The data was collected, stored, and analyzedwith strict compliance to data protection and athleteconfidentiality.All patients were imaged at the official IOC polyclinic inthe Olympic Village using either a 3 T Discovery MR750wor 1.5 T Optima 450MRw MRI scanner (General Electric,Waukesha, Wisc). MRI sequences consisted of 3 planes(axial, oblique coronal, oblique sagittal) of fluid sensitiveT2-weighted or proton density (PD)-weighted fat-suppressedsequences. A coronal or sagittal T1-weighted sequence wasalso acquired. Neither intravenous nor arthrographicGadolinium was utilized.Image interpretationA board certified, subspecialty radiologist (AM) with8 years of musculoskeletal imaging experience includingimaging of sports injuries, retrospectively reviewed allMRI examinations. The radiologist was blinded to theofficial imaging report. All data was recorded on aMicrosoft Excel spreadsheet, and a descriptive statis-tical analysis was performed.Osseous lesions were characterized based on locationand bone marrow signal characteristics. Any bone mar-row hyperintensity or edema pattern on either a T2 orPD-weighted fat-suppressed sequence was considered abone contusion. Any bone marrow edema pattern asso-ciated with osseous fragmentation or a low linear signalon the T1-weighted sequence was considered an acutefracture [12]. Hill Sachs and osseous Bankart lesionswere diagnosed based on their characteristic locationson the posterior superior humeral head and anterior in-ferior glenoid, respectively. A designation of either acuteor chronic was based on the presence of a bone marrowedema pattern [13, 14].Fluid within the subacromial / subdeltoid bursa andwithin the glenohumeral joint was assessed on the T2 orPD-weighted fat-suppressed sequences. Any region ofhyper-intense subacromial or subdeltoid bursal thicken-ing that was 2 mm or greater was considered a bursitis[4]. A glenohumeral joint effusion was characterized ona 4-point scale as reported by Schweitzer et al. Normalintra-articular fluid produces a thin intraarticular rim ofhyperintense signal, but without distension of a joint re-cess. The presence of slight fluid distension of the sub-scapular recess, fluid within the biceps tendon sheath, orfluid within the axillary recess was considered a smallglenohumeral joint effusion. Fluid distension of two ofthese recesses represented a moderate sized effusion.Fluid distension of all three structures represented alarge effusion [15].Each rotator cuff tendon was evaluated for the pres-ence of tendinosis or tear. Tendinosis was diagnosed bythe presence of signal hyperintensity on the PD and to alesser extent T2-weighted images, and or in the presenceof tendon thickening without fiber discontinuity [16, 17].Any morphologic defect of the tendon fibers, eitheralong the bursal surface, intrasubstance, or articular sur-face that was filled with fluid signal, particularly on theT2-weighted sequences, was considered a partial thick-ness defect. A full thickness tear was considered presentif the morphologic defect in the tendon fibers extendedfrom articular surface to bursal surface [18].Any muscle injury of the deltoid or rotator cuff wascharacterized using an MRI-modified version of the Pee-trons classification system [19, 20]; grade 1 – ill-definedhyperintensity on the fluid sensitive sequences indicatingedema signal without architectural distortion of musclefibers or macroscopic tear; grade 2 – architectural dis-tortion of muscle fibers or well-defined hyperintensityon fluid sensitive sequences indicating partial muscletear; and grade 3 – total muscle tear with retraction.The severity of rotator cuff muscle atrophy was assessedusing the Goutallier classification system, which has beenMurakami et al. BMC Musculoskeletal Disorders  (2018) 19:296 Page 2 of 7validated for use in both CT and MRI [21, 22]; grade 1 –some fatty streaks; grade 2 – fatty infiltration, but moremuscle than fat; grade 3 – moderate fatty infiltration butas much fat as muscle; and grade 4 – severe fatty infiltra-tion with more fat than muscle.The morphologic contour and signal of the labrumwas assessed for the presence or absence of tears on theT2 or PD-weighted sequences with or without fat sup-pression. Diagnostic criteria for a tear included the pres-ence of intrasubstance labral high signal, irregular labralmargins, high intrasubstance signal that was non-parallelto the glenoid margin, high signal intensity either poster-ior to the long head of the biceps origin or inferior tothe three o’clock position, or a separation of glenoid andlabrum that was greater than 2 mm. A special distinc-tion of labral tear in association with a Bankart lesionwas made [23, 24].The presence of joint capsule abnormality of theacromioclavicular (AC) joint or the anterior inferior gle-nohumeral ligament of the glenohumeral joint was eval-uated. An acute capsular injury was diagnosed by thepresence of either a frank capsular defect, or by the ab-normal morphology and edema signal both within thecapsule and along the extracapsular margin. A chroniccapsular injury or abnormality was diagnosed by theobservation of a scar thickened joint capsule or cap-sular defect but with an absence of extracapsularedema signal [23, 25].Injuries of the long head of the biceps were character-ized as involving either the extra-articular verticalportion or the intra-articular horizontal portion. The se-verity of injury was assessed by the presence of eithertendinosis, partial tear, or rupture. Tendinosis was de-fined as biceps tendon thickening and /or high intrasub-stance signal on the fluid sensitive sequences. A partialthickness tear was defined as any focal tendon caliberchange or high intrasubstance signal approaching fluidintensity. A complete tear was defined as a complete dis-continuity of the tendon [26].Lastly, cartilage defects were evaluated using a modi-fied Outerbridge classification system on fluid sensitivesequences [27, 28]; grade 1 – heterogeneous signal;grade 2 – shallow ulceration, fibrillation, or fissuring <50% depth; grade 3 – deep ulceration, fibrillation, fissur-ing or chondral flap > 50% depth; grade 4 – full thick-ness loss and exposed subchondral bone.ResultsA total of 11,274 athletes which included 5089 women(45%) and 6185 men (55%) participated in the 2016Olympic Games. The National Olympic Committees andRio 2016 medical staff evaluated a total of 1101 acuteand chronic injuries during the course of the games. Ofthese injured athletes, 55 (5%) were referred for MRI ofthe shoulder for further evaluation of shoulder pain andinjury. The 55 patients included 28 males (51%) and 27females (49%) with an average age of 26 years, rangingfrom 18 to 34. The patients came from 20 differentOlympic sports; of these, swimming (6), judo (6), boxing(5), gymnastics (5), volleyball (5), and athletics (trackand field) (4) provided the most number of patients. Ofall the MRIs, only 2 (4%) were considered completelynormal. The remaining 53 (96%) MRI studies each hadtwo or more abnormal findings.Osseous abnormalitiesTwo patients presented with an acute fracture. This in-cluded an acute Hill Sachs deformity and one highlycomminuted fracture of the scapula. Seven patients sus-tained a bone contusion by study criteria.Anterior instabilitySeven patients presented with evidence of an anteriorshoulder dislocation. Boxing, taekwondo, rugby, athletics(track and field), judo, basketball, and wrestling wereeach represented. One of these patients sustained anacute Hill Sachs injury in combination with a soft tissueBankart lesion (anterior inferior labral tear, Fig. 1) andacute capsular tear of the anterior inferior glenohumeralligament. The six other patients had chronic Hill Sachsdeformities as evidenced by the classic bony contour ab-normality of the superior humeral head, but with a lackof bone marrow edema signal. Two of the patients alsohad an osseous Bankart deformity, while the remainingfour patients had a purely soft tissue displaced anteriorinferior labral tear.Fig. 1 Female rugby player in her late 20’s: Axial T2-weightedfat-suppressed MRI demonstrates tear of the anterior inferior labrum(Bankart) lesion (arrow) and adjacent high grade chondral loss overthe glenoidMurakami et al. BMC Musculoskeletal Disorders  (2018) 19:296 Page 3 of 7Rotator cuffAbnormalities of the rotator cuff were common in thissample, being observed in up to 49 patients (89%).Swimming, volleyball, judo, gymnastics, and track andfield provided the most patients. The highest proportionof athletes per number of participants came from volley-ball, judo, and gymnastics. Distribution of rotator cuffinjury are listed by sport (Table 1).Of the total patients, 22 presented with tendinosisonly, while 27 had a partial thickness tear of the tendon(Fig. 2). There were no patients with either full thicknessor complete rupture of a tendon. Nine patients demon-strated additional edema signal within the muscle andmyotendinous junction of the rotator cuff which wasinterpreted as an acute, low grade muscle strain. Thedistribution of the rotator cuff tendons involved in eithertendinosis (Fig. 3) or partial tear (Fig. 4) was similar.LabrumTears of the superior labrum anterior posterior (SLAP),were relatively common, seen in 30 patients (55%). Thir-teen of these SLAP tears were accompanied with abnor-malities of the intra-articular long head of the biceps;seven patients had a partial thickness tear of the bicepswith their SLAP tear, while 6 had at least tendinosis ofthe biceps. The distribution of SLAP tears are listed bysport (Table 2). Gymnastics had the highest proportionof SLAP tears relative to the total number of Olympicparticipants.Long head of the biceps tendonAbnormalities of the biceps tendon were present in 16patients. Only 1 had involvement of the vertical portion,which presented as a partial tear. The remainder of thesepatients had involvement of the horizontal portion ofthe tendon. Thirteen of these patients (87%) were in as-sociation with a SLAP tear and are described in detailabove. The remaining 2 patients had tendinosis.BursaA subacromial / subdeltoid bursitis was present in 29patients (40%).Table 1 Distribution of rotator cuff abnormality by per sportSport Patients Total Numberof ParticipantsFraction ofpatients to the# of participantsAquatics - Swimming 6 901 0.007Volleyball 5 288 0.017Judo 5 390 0.013Gymnastics - Artistic 5 194 0.026Athletics (Track and Field) 4 2367 0.002Wrestling 3 349 0.009Cycling - Road 3 211 0.014Boxing 3 289 0.010Tennis 2 199 0.010Rugby 2 291 0.007Handball 2 335 0.006Weightlifting 1 256 0.004Taekwondo 1 127 0.008Hockey 1 384 0.003Football 1 503 0.002Field Hockey 1 384 0.003Canoe - Sprint 1 248 0.004Beach volleyball 1 96 0.010Basketball 1 287 0.003Aquatics - Water polo 1 258 0.004Fig. 2 Male gymnast in his late 20’s: Coronal T2-weighted fat-suppressedMRI shows superior labral tear and overlying paralabral cyst (arrow) and alow grade intrasubstance tear of supraspinatus tendon (arrowhead)Fig. 3 Distribution of rotator cuff tendinosisMurakami et al. BMC Musculoskeletal Disorders  (2018) 19:296 Page 4 of 7JointsA joint effusion was seen in 23 patients (42%). In all butthree of these patients, the size was considered small.Degenerative glenohumeral chondral loss was notedin 13 total patients (24%). Track and field (3) andgymnastics (2) provided the most patients. Of thetotal, 10 patients had chondral defects that were con-sidered either an Outerbridge 3 or 4. Five of the pa-tients (38%) with chondral loss had either a HillSachs deformity or osseous/soft tissue Bankart lesionor both. Nine of these patients (69%) with chondralloss also had a SLAP tear.In regards to the AC joint, four patients demonstratedcapsular defects, two acute and two chronic. Sixteen pa-tients had evidence of either mild to moderate chondralloss of the AC joint.DiscussionAcute and chronic shoulder injuries are common prob-lems in elite athletes. Sports with overhead throwing ac-tivities have been most frequently studied, with theprevalence of shoulder pain reported to be anywhere be-tween 23 and 36% [7, 8]. This is ultimately attributed tothe relatively unnatural and highly dynamic nature ofthe throwing movement. A strict balance of the dynamicand static stabilizers are needed to maintain a stablecenter of rotation [29], and loss or damage of these sup-porting structures can lead to shoulder pain as well as adecrease in performance. There are many additionalsports in which repetitive overhead motion is inherentin competition, also leading to shoulder pain. For ex-ample, in elite, competitive swimmers, limiting shoulderpain has been reported to be between 40 and 90%[30–32]. In such cases, the etiology is most likely similarand backed by studies which have analyzed gleno-humeral kinematics; With increasing rotator cuff fa-tigue, there is superior migration of the humeral headduring arm elevations which leads to impingementand rotator cuff injury [33, 34].Our findings are in line with this etiologic theory,given the high percentage of rotator cuff abnormalitiesand subdeltoid bursitis occurring in athletes involved incontact or overhead motion sports. In comparison to thegeneral population, a review of the published literatureperformed by Teunis et al. [35] found that the preva-lence of any rotator cuff abnormality (tendinosis or tear)is 9.7% in individuals less than 20 years, and 6.9% inthose from 20 to 29 years. This is in contrast to ourstudy patients, in which 89% demonstrated a rotator cuffabnormality (tendinosis or tear). The relatively even ten-don distribution of the tears and tendinosis involvingsupraspinatus, infraspinatus, and subscapularis doesslightly deviate from the previously described pathologiccontinuum of chronic subacromial impingement leadingto predominantly supraspinatus tendinosis and tear [36].However, the diversity of cuff involvement evident inthese athletes may reflect the diversity of sports.Labral injury, like rotator cuff injury, generally has ahigh prevalence in symptomatic and asymptomatic eliteathletes. While the incidence is most commonly associ-ated in sports with repetitive overhead motion or throw-ing, it has also been seen in contact athletes [4–6, 9].For example, the incidence of SLAP tears in elite rugbyplayers has been found to be as high as 83% [10, 11].Our reported overall occurrence of SLAP tears at 55% iscomparable to prior published studies on elite athletes.Also in keeping with the published data, the distributionof labral tears is mostly with sports with inherent over-head motion or contact.Of patients with glenohumeral chondral loss, 85% hadeither evidence of anterior shoulder instability and priorFig. 4 Distribution of rotator cuff partial tearTable 2 Distribution of superior labrum anterior posterior(SLAP) tears by sportCases Total Number ofIOC ParticipantsFractionJudo 4 390 0.010Gymnastics 4 194 0.021Wrestling 3 349 0.009Volleyball 3 288 0.010Athletics (Track and field) 3 2367 0.001Swimming 3 901 0.003Tennis 2 199 0.010Rugby 2 291 0.007Cycling - Road 2 211 0.009Football 1 503 0.002Boxing 1 289 0.003Basketball 1 287 0.003Water polo 1 258 0.004Murakami et al. BMC Musculoskeletal Disorders  (2018) 19:296 Page 5 of 7dislocation and / or a superior labral tear. This is an en-tirely expected finding, as it is established that chronicshoulder instability can eventually lead to chondral loss.Previous studies have demonstrated that the incidenceof chondral damage to be as high as 9.2% in patientswith anterior shoulder instability [37] and up to 64% inpatients undergoing arthroscopic Bankart repair [38].Our study had several inherent limitations. As astrictly observational study, we did not analyze the med-ical record to correlate the clinical exam findings withthe reason of study. Other than the clinical diagnosis ofshoulder pain as an indication for MRI, we lacked de-tailed knowledge of clinical information that would bet-ter link our imaging findings to the clinical presentation.Our patient population inevitably included both acuteinjuries and pre-existing conditions. It is also possiblethat some of the observed imaging findings can beseen in asymptomatic individuals, and thus, establish-ing a direct cause and effect link is not possible giventhe retrospective study design and beyond the scopeof this paper.The overall prevalence of Olympic athletes in ourstudy being evaluated for shoulder pain (5%) is certainlylower than prior reported values in overhead throwingathletes [7, 8]. This however, is likely a reflection of thediversity of Olympic sports as well as the selection biasgeared toward a group of patients in which MRI imagingwas indicated. We did not include other modalities thatare routinely used to evaluate shoulder pain, which in-clude ultrasound, radiograph, and computed tomography(CT). This means we likely have an underestimation ofthe overall athletes evaluated for shoulder pain. Thus, thisstudy is a modality specific analysis rather than a study ofoverall injury prevalence.In regards to our image interpretation, using one obser-ver limited our ability to study intra-and inter-observervariability. It has also been shown that a higher MRI im-aging matrix, stronger field strength, and intra-articularcontrast (arthrography) increase the sensitivity of diagnos-ing labral tear [39–41]. In our study, both 3 T and 1.5 TMRI scanners were used and no arthrograms were per-formed. Thus, it is possible that our study lacked optimalsensitivity for labral tear detection. Furthermore, we donot know if any of these elite athletes underwent surgeryfor their shoulder pathology and their outcomes.ConclusionsOur study demonstrates a high rate of bursal, rotatorcuff, and labral pathology in Olympic athletes receivingMRIs at the 2016 Rio de Janeiro Summer OlympicGames. These findings imply that some degree of gleno-humeral instability and impingement is occurring, likelydue to fatigue and overuse of the dynamic stabilizers.Due to the diversity of Olympic sporting events, we lacksufficient numbers to draw any further sport-specificconclusions to the injuries exhibited here. More conclu-sive patterns may emerge by a combined analysis withfuture Olympic competitions. Since the cumulative effectof chronic injury and overuse syndromes in the elite ath-lete is an atypically higher rate of osteoarthritis [42],ultimately, it is our interest to continue understandingproblems that affect those who have made such greatsacrifices to represent their countries in internationalcompetition.AbbreviationsAC: Acromial Clavicular; CT: Computed Tomography; IOC: International OlympicCommission; IRB: Institution Review Board; MRI: Magnetic Resonance Imaging;PACS: Picture archiving communications system; PD: Proton Density;RIS: Radiological Information System; SLAP: Superior Labrum Anterior PosteriorAcknowledgementsWe would like to thank IOC members and all staff of Olympic Village imagingcenter and sports physicians/radiologists who provided clinical service.Availability of data and materialsThe datasets generated and / or analyzed during the current study are notpublicly available due to the maintenance of patient / athlete confidentiality,but are available from the corresponding author on reasonable request.Authors’ contributionsAMM assessed the data, design of the analyses, wrote the first draft and revisionof the manuscript. AJK data analysis and interpretation, and commented on alldrafts of the manuscript. LE collected the data at the Olympics, commented onall drafts of the manuscript, and final approval of the version to be published. XLdata analysis and commented on all drafts of the manuscript. BBF data analysisand commented on all drafts of the manuscript. MDC performed severalexaminations on site at the Olympics, contributed in the acquisition ofthe data and commented on all drafts of the manuscript. DH contribution tothe conception of the work and commented on all drafts of the manuscript. MJclean the data and data analysis and commented on all drafts of the manuscript.FWR interpretation of the data and commented on all drafts of the manuscript.AG conception of the work, analyses and interpretation of the data, commentedon all versions of the manuscript, final approval of the version to be publishedand guarantor of accuracy and integrity of the data. All authors readand approved the final manuscript.Ethics approval and consent to participateThis study was approved by the medical research ethics committee of theSouth-Eastern Norway Regional Health Authority (2011/388) and was exemptfrom Ethics Committee approval. Additional Institution Review Board (IRB)approval was obtained from Boston University (#H-36593). Informed writtenconsent was waived since all epidemiological data was anonymized andunidentifiable. The use of anonymized imaging and demographic data forpublication was approved by the IOC.Consent for publicationNot applicable.Competing interestsAli Guermazi is the President of Boston Imaging Core Lab (BICL), LLC, and aConsultant to MerckSerono, AstraZeneca, Pfizer, GE Healthcare, OrthoTrophix,Sanofi and TissueGene. Frank Roemer and Michel Crema are shareholders ofBICL, LLC. Lars Engebretsen is a consultant to Arthrex and Smith and Nephew.Bruce Forster has an equity position with a private MRI clinic in Vancouver. AkiraMurakami, Andrew J. Kompel, Xinning Li, Daichi Hayashi, and Mohamed Jarrayahave nothing to disclose.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Murakami et al. BMC Musculoskeletal Disorders  (2018) 19:296 Page 6 of 7Author details1Section of Musculoskeletal Imaging, Department of Radiology, BostonUniversity School of Medicine, FGH Building, 3rd Floor, 820 Harrison Ave.,Boston, MA 02118, USA. 2Medical and Scientific Department, InternationalOlympic Committee, Lausanne, Switzerland. 3Oslo Sports Trauma ResearchCenter, Department of Sports Medicine, Norwegian School of Sport Sciences,Oslo, Norway. 4Department of Orthopedic Surgery, Oslo University Hospital,University of Oslo, Oslo, Norway. 5Department of Orthopaedic Surgery,Boston University School of Medicine, Boston, MA, USA. 6Department ofRadiology, University of British Columbia, Vancouver, BC, Canada.7Department of Sports Medicine, National Institute of Sports (INSEP), Paris,France. 8Department of Radiology, Saint-Antoine Hospital, University Paris VI,Paris, France. 9Department of Radiology, Stony Brook Medicine, Stony Brook,NY, USA. 10Department of Radiology, Mercy Catholic Medical Center, Darby,PA, USA. 11Department of Radiology, University of Erlangen-Nuremberg,Erlangen, Germany.Received: 15 May 2018 Accepted: 6 August 2018References1. 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