British Athletics muscle injury classifiaction: A validity

study for a new grading system

Poster No.: C-0336

Congress: ECR 2015
Type: Scientific Exhibit
Authors: 1 1 2 3
A. Patel , S. L. J. James , J. Chakraverty , N. Pollock , R.
3 1 2 3
Chakraverty ; Birmingham/UK, Cardiff/UK, London/UK
Keywords: Athletic injuries, Observer performance, MR, Musculoskeletal soft
tissue
DOI: 10.1594/ecr2015/C-0336

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Aims and objectives

AIMS AND OBJECTIVES

The British Athletics Muscle Injury Classification has the potential to accurately classify
hamstring injuries, which may improve assessment and treatment of such injuries.
However, this classification is new and its reliability has not been established. The
purpose of our study is therefore to examine the interrater and intrarater reliabilities of this
new classification system, and to analyze the nature and frequency of disagreements.

BACKGROUND

Muscle injuries are common in sport resulting in a significant amount of time lost from
training and competition. Most injuries sustained during track and field competition were
attributed to muscle injuries with the hamstring group being most common [1]. Accurate
grading of muscle injuries is important for both clinicians and athletes, and the ultimate
goal of an injury classification system would be to guide clinical management and provide
prognostic information to predict recovery and time off from competition.

The most widely used muscle injury grading systems,[2, 3] are relatively simplistic,
comprising 3 grades of muscle injury based on imaging findings. Grade 1 represents a
strain, grade 2 represents a partial thickness tear and grade 3 a full thickness tear,[4-9].
Prognostic information on muscle injury is now available based on newly available MRI
data including:

• The length of muscle tear [2, 8]

• MRI 'negative' injuries [2, 3, 9]
• Distance from the origin of injury [10]
• Cross sectional area of oedema [11,12]
• Tendon involvement [10, 12, 13]

The old classification systems do not consider the MRI parameters that have
demonstrated some prognostic relevance potentially resulting in a number of different
injuries (with different treatment and rehabilitation regimens) being categorised into a
single group.

A new British Athletics Muscle injury grading has been proposed [Figure 1] based on
current evidence to assist in the classification and potential clinical management and
prognostication of injuries. It has been developed primarily for hamstring injuries in track
and field athletes.

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Images for this section:

Fig. 1: British Athletics Muscle (BAM) Injury classification.

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Fig. 2: Figure 2. Schematic diagram of hamstring injury types. a) Myofascial injury b)
Musculotendinous junction Injury c) Intratendinous extension. Image by Louise Carrier

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Methods and materials

MATERIALS AND METHODS

81 MRI scans of elite track and field athletes with suspected hamstring injuries performed
between 02/2010 and 04/2014 were identified and retrospectively reviewed. Fifteen of the
81 scans were performed for reasons other than suspected hamstring injury and one was
a repeat study, and therefore 16 scans were omitted giving a total of 65 MRI studies from
45 patients available for the analysis. Ethical approval was granted for the retrospective
imaging and data analysis performed in this study.

IMAGING PROTOCOL

MR imaging was performed on a number of different manufacturer systems at 1.5 or 3

Tesla. In most instances, skin markers (cod liver oil capsule) were placed at the site of
maximum symptoms. Sequences were dependent on the original institution at which the
examination was undertaken. A typical protocol included a combination of axial, coronal
and sagittal STIR (short tau inversion recovery)/ T2 weighted fat suppressed / proton
density weighted fat suppressed sequences followed by axial and sagittal T1 weighted
sequences.

For our study, the images were electronically transferred to a secure electronic database
and reviewed using the 32 bit OsiriX DICOM viewer system on the Apple platform.

GRADING

Two specialist musculoskeletal radiologists independently reviewed all MRI studies and
graded the injuries according to the new classification system. All images were reviewed
by both radiologists initially (Round 1) and again after a four-month period (Round 2).
When more than one muscle was involved the muscle with the worst injury was scored.
All results were recorded onto a designated proforma.

STASTICAL ANALYSIS

An independent observer, not involved in the study, performed all the statistical analyses.
Inter- and intrarater reliabilities were calculated using the percent agreement and Cohen's
kappa statistic. Percentages of agreement were calculated as the number of agreements
in observations divided by the total number of observations.

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Interrater reliability was assessed by comparing the two raters separately for each round,
and intrarater reliability by comparing each rater's selections from the two rounds. The
Landis and Koch guideline for interpreting Cohen's kappa values was used (see below).
All statistical calculations were performed using StatsDirect software (StatsDirect Ltd,
Cheshire, UK).

Kappa value Strength of agreement

-1 Complete disagreement
<0 Poor
0-0.20 Slight
0.21-0.40 Fair
0.41-0.60 Moderate
0.61-0.80 Substantial
0.81-10 Almost perfect
1 Complete agreement

Results

RESULTS

The British Athletics Muscle Injury Classification demonstrated excellent interrater Kappa
values of 0.80 (95% CI 0.67-0.92; P < 0.0001) for Round 1 and 0.88 (95% CI = 0.76-1.00;
P < 0.0001) for Round 2 of the review. The percentages of agreement were 85% for
Round 1 and 91% for Round 2. The intrarater Kappa value for the two reviewers were 0.76
(95% CI 0.63-0.88; P < 0.0001) and 0.65 (95%CI 0.53-0.76; P < 0.0001) and the average
was 0.71 suggesting substantial overall agreement. The percentages of agreement were
82% and 72% respectively.

During the first round of scoring there were 10 studies out of the 65 where there was a
discrepancy in the scoring. During the second round of scoring there were six studies
out of the 65 where there was a discrepancy in the scoring. A third musculoskeletal
radiologist reviewed cases where disagreement occurred to give a definitive score. This
was undertaken to allow these cases to be further analyzed to see why differences in
opinion regarding injury grade occurred. A breakdown of the nature and frequency of
disagreements between the two raters for each round of scoring is presented in Figure 3.

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Images for this section:

Fig. 3: Figure 3. Nature of discrepancies per round of scoring.

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Page 8 of 16
Fig. 4: Sagittal STIR image of the thigh showing tracking oedema (white arrow) extending
beyond the muscle abnormality (black arrow). This oedema can track along fascial
planes, which can potentially result in overgrading the injury.

Fig. 5: Branching vessels (white arrows) are seen proximal to an intramuscular injury
(black arrow). Note how the branching vessels may look similar to the feathery oedema
pattern of a muscle injury.

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Fig. 6: Image shows a thickened conjoined tendon but has intratendinous high signal
within it (black arrow) and peritendinous oedema suggesting an acute "c" injury on the
background of old tendon thickening from a previously sustained injury.

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Fig. 7: Note the increased thickness of the left conjoined tendon (white arrow) compared
to the contralateral side indicating chronic injury. No significant high signal is seen in the
tendon or peritendinous region to suggest an acute injury. (see comparison with figure 6)

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Fig. 8: Figure 8 and 9 pertain to the same patient. Note how on the axial images the injury
looks like it is a musculotendinous injury, the coronal image below (Figure 9) shows loss
of tension in the tendon which appears wavy

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Page 13 of 16
Fig. 9: Figure 8 and 9 pertain to the same patient. Note how on the coronal image shows
the loss of tension (wavy tendon) rather than its normal taught appearance

Page 14 of 16
Conclusion

CONCLUSION

Muscle injuries during sport are commonly encountered and are a significant cause
of loss of time from training and competition. Prognostic information based on certain
imaging features, particularly intratendon injury, has been widely investigated in the
literature. A classification system that does not incorporate this evidence will not provide
adequate information to guide clinical management or assist prognostication. The newly
proposed British Athletics classification aims at improving this by including imaging
features, particularly intratendon involvement.

This study has shown that this classification system is simple to use and produces both
reproducible and consistent results based on interobserver and intraobserver reliability
with at least substantial agreement in all groups based on calculated kappa values.
We believe that as radiologists/clinicians become more familiar with this classification
system the interrater and intrarater reliability values are likely to improve (as was seen
in this study between the 2 scoring rounds). Further work is required to investigate how
individual grades within this classification system influence clinical management and
assist with prognostic information.

Personal information

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