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Operator can heal without making an injury worse or allow TABLE 1 MRI Frequency
the Operator to continue training after ruling out an injury Site Frequency, n
that requires surgical intervention, PT, or rest. MRIs should Knee 10
be included as a first-line diagnostic tool to aid in the rapid Shoulder 9
and definitive diagnosis of orthopedic injury in the Operator
community. Elbow 3
Lumbar spine 3
Earlier use of MRI over plane X-rays is appealing for several Cervical spine 3
reasons, including increased ability to definitively diagnose Ankle 3
soft-tissue or cartilage injury requiring surgery, increased mis- Wrist 2
sion readiness, and elimination of unnecessary exposure to IR. Tibia and fibula 1
We undertook this study to review the results of experience Foot 1
with early MRI among PJs and combat rescue officers com-
plaining of pain or dysfunction due to injury. A secondary TABLE 2 Diagnosis by Injury Type
objective was to determine if there was a high positivity rate
due to the nature of the men selected for this work (i.e., high Injury Type Frequency, n
thresholds of pain and complaining). Tendon 8
Other soft tissue 7 a
Bone 7
Patients and Methods Cartilage 6
This performance improvement project was approved by the Disc 6
institutional review board of the Air Force Research Oversight Ligament 5
and Compliance Division. Arthropathy 5 b
a Bursitis, fasciitis, muscle tear, popliteal cyst.
From April 2008 through December 2014, the injuries of 45 b Bone contusions, periosteal reaction, bone cyst.
PJs on a single team were managed by a single flight surgeon.
On injury or complaint of worsening of an intermittent or 18 PJs examined required surgery; surgery was required for
chronic injury associated with significant pain or dysfunction eight of 15 PJs if the lumbar spine MRIs are excluded (spine
(e.g., weakness or decrease range of motion), MRI was or- MRI was performed for pain in the absence of weakness or
dered and performed anytime from 1 day to about 1 week sensory loss). In all cases of surgical intervention, treatment
later. A single musculoskeletal radiologist (C.F.), who became was definitive. In nonsurgical cases, PT, active recovery, con-
familiar with the Operators and the job demands, read ev- tinued training, and rest were prescribed on the basis of the
ery MRI. Records were maintained prospectively and collated exact diagnoses.
retrospectively. Information regarding the indication for MRI,
mechanism of injury (MOI), anatomic site, diagnoses, and Of the 35 MRIs performed, including the spine MRIs, 21
treatment was recorded. (60%) were positive and directed Operators for further care,
rest, or resumption of training.
The same musculoskeletal radiologist, flight surgeon, and
sports fellowship–trained orthopedic surgeon reviewed all re-
sults and, when necessary, discussed the treatment plan, which Discussion
incorporated the operational and clinical perspectives. In most Approximately one-half of the Operators (eight of 15) who
instances, MRI was performed before orthopedic consultation. underwent MRI (excluding lumbosacral studies) over 6.5
years required surgical intervention. In a small squadron com-
Results posed of 45 total Operators, 35 MRIs were performed on 18
individuals (40%), of whom eight (17.7% of the total Oper-
Eighteen Operators (40%) underwent a total of 35 MRIs. The ators on the team) required surgical intervention. Therefore,
most common sites imaged were the knee and shoulder (n = 10 during the observed time period, almost one in five Operators
and 9, respectively), followed by elbow, cervical spine, lumbar underwent surgery.
spine, and ankle (Table 1). The MOI was categorized as over-
use in 16 patients, military training (e.g., parachuting, adverse It should be noted that all surgeries resulted in clinical im-
terrain training, battle drills) in 11, acute physical training in- provement. Surgeries were not performed for diagnosis of
jury in six, acute sports injury in one, and unknown in one. injuries such as small labral or meniscal tears not felt to be
clinically significant. This may be a reflection of the team ap-
The most common diagnoses were related to ligament and proach including a musculoskeletal radiologist and orthopedic
tendon injuries (n = 18; Table 2). There were three bone con- sports surgeon, who have developed a good rapport with the
tusions, and there were disc protrusions on the four spine flight surgeon and the team, which includes an understanding
studies. The only pure bone abnormalities that would have of the Operators and their job and the notion that they do not
shown up on chest radiographs were two cases of distal cla- come to the flight surgeon for minor complaints.
vicular osteolysis.
If these Operators presented to a general medical group, the
Treatment was guided by the results. Eleven of the injuries re- standard approach would be conventional radiograph fol-
viewed with MRI were treated with surgical intervention; no lowed by 6 weeks of PT. If this is not successful, the patients
spine injuries viewed with MRI were treated surgically. There- are then referred for an orthopedic consultation, then MRI,
fore, 11 of the injuries viewed with MRI among eight of the and then scheduling surgery, if indicated. This would result in

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