Page 88 - JSOM Summer 2018

The Role of Magnetic Resonance Imaging in
Optimizing Injury Management in Air Force Pararescuemen,
Combat Rescue Officers, and Survival Specialists

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Stephen C. Rush, MD *; Christopher M. Foresto, MD ; Christopher W. Hewitt, MD ;
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Marc G. Grossman, MD ; Christopher D. Petersen, BS, NREMT-P ;
Isabelle A. Gallo, BS, NREMT-P ; Brian P. Staak ; Jessica T. Rush, MD 8
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ABSTRACT
Operators perform physically demanding jobs associated with deployments. Frequently, many cumulative and overuse inju-
a variety of overuse and acute musculoskeletal injuries. The ries manifest in older Operators, who are typically the most
current management of musculoskeletal complaints in the Air experienced, thereby reducing their ability to train younger/
Force includes plane radiographs and 6 weeks of physical ther- newer individuals and to occupy important positions during
apy (PT) before consideration of orthopedic consultation and contingency operations.
magnetic resonance imaging (MRI); however, MRI shows a
clear advantage compared with plane radiographs. We con- Currently, in the Air Force, radiographs are the first-line di-
ducted a performance improvement project and conclude that agnostic tool when Operators present to their physician or
(1) MRI allowed for definitive diagnosis as well as definitive clinic with symptoms of musculoskeletal complaints. X-rays,
triage for care in a timely manner, (2) guidelines for ordering which are a form of ionizing radiation (IR), are high-frequency
lumbosacral MRIs should be followed and not ordered for electromagnetic waves that can ionize atoms and subsequently
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pain that is not progressive and severe or not associated with damage DNA and cellular molecules. One of the long-term
a neurological finding, and (3) because of the risk of X-ray outcomes of this can be carcinogenesis. 3
exposure in patients in their 20 and 30s, X-rays should be
avoided in this setting unless definitely indicated. Although radiographs have long been the standard tool for
diagnosing fractures, fractures are rarely the root cause of pain
Keywords: radiography; X-rays; magnetic resonance imag- in the vast majority of physical training and chronic injuries
ing; injuries, musculoskeletal; imaging sustained by Operators; these are generally soft-tissue injuries,
including ligament and tendon injuries. Diagnosing injuries
in this manner results in frequent, unnecessary IR exposure.
This is particularly important because Operators are generally
Introduction in their 20s and 30s and thus have decades to manifest this
PJs and combat rescue officers (referred to collectively as Op- complication. The medical community has long acknowledged
erators in this article) perform physically demanding jobs as- that X-rays can be harmful; during the early years of X-ray
sociated with a variety of overuse and acute musculoskeletal use, nearly one-half of all physicians trained in X-ray radiol-
injuries. Operators are selected through courses designed to ogy had radiation damage in the hands, including carcinogenic
test an individual’s resiliency and mettle, which tends to re- effects. 3
sult in candidates selected to have higher tolerance for pain
and suffering. In a 2013 survey conducted by the Hospital for Alternatively, MRI is a noninvasive imaging modality without
Special Surgery, 34 of 35 Operators reported suffering from at the harmful IR effects that can result from X-rays. Diagnos-
least one orthopedic injury during their time in the military. tic ability aided by MRI is exponentially more effective when
The most common sites of injury (percentage of individuals identifying soft-tissue injuries compared with radiographs,
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affected by such injuries) include the foot and ankle (22%), ultrasound, and even computed tomography (CT). Further-
shoulder (21%), spine (19%), knee (17%), wrist/hand (10%), more, many injuries observed in the Operator community
elbow (8%), and hip (2%), as well as general low back pain/ involve long-term joint overuse with prearthritic symptoms.
tightness, tendinitis (not joint specific), and nerve injuries. 1 Details of this pathology are not always evident with the use of
radiographs alone, and MRIs can reveal subtle joint structural
The current management of musculoskeletal complaints in the changes long before they appear on conventional radiography. 4
Air Force includes plane radiographs and 6 weeks of PT before
consideration of orthopedic consultation and MRI. Rapid di- Early use of MRI for musculoskeletal injuries, which are not
agnosis and treatment are imperative because they will result primarily skeletal, would reduce the time from injury to di-
in less deconditioning from reduced downtime from training agnosis and thus decrease Operator downtime. Timely and
(both job specific and physical conditioning) and increased accurate diagnosis would then allow clinical decision making
mission readiness for real-world contingency Operations and to rapidly proceed to surgery, PT, or activity reduction so the

*Address correspondence to stephencrush@mac.com
1 Dr Rush is a US Air Force (USAF) pararescue flight surgeon. Dr Foresto is with the Nassau Radiologic Group, New York University School of
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Medicine. Dr Hewitt is a USAF emergency medicine resident. Dr Grossman is with the Orthopedic Surgery Department, Winthrop University
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Hospital. Mr Petersen, PJ, MS-1, Hofstra University College of Medicine, is a USAF Pararescue, NREMT-P. Ms Gallo is at Stony Brook Univer-
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sity. Mr Staak, MS-2, USUHS, is a USAF Pararescue, NREMT-P. Dr Rush is a resident at Dartmouth Medical School, Mt Sinai Hospital, NY.
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