Imaging in elite and recreational cricket injuries: A pictorial review

Craniofacial injuries

Although cricket is a non-contact sport, multiple impact injuries, including fractures, are common in it. These are most commonly due to the cricket ball in the head and neck region. The zygomatic bone is the most common facial bone to be fractured. Nasal bone fractures can also occur, as can soft tissue and bony orbital injuries.^[2] Concussions occur in cricketers due to being struck by the cricket ball. Computed tomography (CT) or magnetic resonance imaging (MRI) of the brain is indicated in a patient with a concussion in the presence of red flag signs such as loss of consciousness, post-traumatic amnesia, focal neurological deficit, Glasgow coma scale of <15, and signs of clinical deterioration.^[3,4]

Upper limb

Shoulder injuries are common in cricket.^[5] These include rotator cuff tears, labral tears, glenohumeral dislocations resulting in Hill-Sachs and Bankart lesions, and biceps tendon tears. Chronic injuries such as rotator cuff tendinosis and acromioclavicular joint arthritis can also occur. Lateral and medial epicondylitis also occur in cricketers as chronic overuse injuries. Athletes with a predominantly posterior attachment of the biceps tendon to the labrum may be at increased predisposition for superior labrum from anterior to posterior tears.^[6] An Australian study found a high prevalence of shoulder injuries in spin bowlers, followed by fast bowlers and fielders.^[7]

Another injury seen in throwing athletes, including cricket fielders, is valgus overload syndrome, a triad of capitellar osteochondral injury or osteonecrosis, ulnar collateral ligament injury, and posterior elbow impaction injury.^[1]

Wrist injuries include tendinosis of various flexor or extensor tendons. Triangular fibrocartilage complex injuries and injuries of the intrinsic or extrinsic ligaments of the wrist also occur [Figure 1]. Hand and finger injuries from ball impact are common in fielders and batsmen. Volar plate avulsion fractures are seen in fielders while trying to catch the ball, resulting from hyperextension from ball impact at the proximal interphalangeal joint, injuring the volar plate [Figure 1]. Various fractures of the fingers and thumb are common in cricketers, most common from impact from the cricket ball.^[1] We also encountered a case of ulnar collateral ligament injury at the second metacarpophalangeal joint in an off-spin bowler, most likely from repeated motions of gripping and spinning the ball [Figure 1].

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Figure 1:

Hand and wrist injuries in cricket. (a and b) Batsman with fall on outstretched hand while running between the wickets. Coronal proton density (PD) fat sat images show a complete tear of dorsal and volar radio-ulnar ligaments (a) and a complete tear of the radial collateral ligament (b) with mild edema in the adjacent radial styloid process (arrows). (c) The fielder with a hyperextension injury to the third finger while trying to catch the ball. The sagittal computed tomography image shows an avulsion fracture at the base of the middle phalanx with a fracture line extending into the proximal inter-phalangeal joint. This represents a volar plate avulsion fracture. (d) Off-spin bowler with long-standing pain in the second metacarpo-phalangeal joint. Coronal PD fat sat magnetic resonance imaging images show a partial tear of the ulnar collateral ligament of the second metacarpo-phalangeal joint, postulated to be a chronic overuse injury from spinning the ball (“Off-spinner’s finger”).

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Thorax

Rib fractures can occur in cricket, as can various bruises and contusions from the cricket ball [Figure 2]. The rib injuries can be in the form of avulsion fractures associated with side strain or can be lower rib periostitis, which is an overuse injury causing thoracolumbar back pain. Both these injuries are common in cricket fast bowlers.^[1]

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Figure 2:

Cricketer with left thoracic wall pain following impact from a ball while batting (such a ball being colloquially called a “rib tickler”). (a) Axial T1 image shows hypointensity in the left rib marrow. (b) and (c) Axial and coronal short-tau inversion recovery images show marrow edema in the rib with adjacent soft-tissue edema. The athlete had a linear, minimally displaced rib fracture.

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Spine

A lumbar stress fracture is the most severe injury in modern cricket, resulting in a significant loss of playtime.^[5] These are common in fast bowlers and usually occur opposite to the bowling arm [Figure 3]. These can be acute injuries or chronic ones due to overuse. The injury spectrum ranges from a stress reaction to incomplete stress fracture, complete stress fracture, and chronic stress fracture. Studies show the prevalence of these bony changes on MRI in 24–81% of fast bowlers.^[1] An optimum imaging protocol will consist of T1 and T2 sagittal as well as short-tau inversion recovery images in two planes (sagittal and axial) to visualize bone marrow edema for stress reactions and T1VIBE sagittal.

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Figure 3:

Fast bowler with low back pain. (a) coronal, (b) sagittal, and (c) axial magnetic resonance imaging short-tau inversion recovery images demonstrate edema in the left pars interarticularis of L3 vertebra (white arrows), without cortical breach. This indicates a stress reaction of the pars interarticularis.

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Abdominal wall and side strain

Side strains are common in elite cricketers, most commonly in fast bowlers, but also in batsmen and fielders. They usually occur on the side opposite to the bowling arm. They involve tears of the lateral abdominal wall muscles, with the most common muscle injured being the internal oblique. Injuries can occur near the ribs adjacent to the origin of the internal oblique or near the iliac crest attachment. Associated avulsion fractures of ribs are shown in Figure 4.^[6] An ideal imaging protocol would include the lower three ribs till mid-pelvis in all three planes, with the axial and sagittal scans centered on the side of the pathology.

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Figure 4:

Fast bowler with acute onset pain in the left lateral aspect of the abdomen. (a) axial, (b) coronal, and (c) sagittal magnetic resonance imaging short-tau inversion recovery images demonstrate a complete tear of the left internal oblique muscle near its origin from the lower ribs (white arrows). (d) Coronal computed tomography image shows an avulsion fracture of the left 11^th rib at the site of attachment of internal oblique muscle (arrow).

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Pelvis and groin

Athletic pubalgia is common in cricketers.^[7] Rectus abdominis and adductor injuries can occur with or without marrow edema in pubic bone [Figure 5]. An optimum imaging protocol would focus on the rectus abdominis insertion-adductor origin region and pubic symphysis with short field-of-view images, with the inclusion of fat-saturated images to visualize muscle and bone marrow edema.

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Figure 5:

Cricketer with right groin pain. Magnetic resonance imaging short-tau inversion recovery coronal image shows a complete tear of the right adductor longus muscle 4 cm below its origin, with complete separation of fibers and fluid signal intensity/hematoma (white arrow). There is edema in the adjacent muscle fibers.

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Lower extremity

Hamstring injuries are the most common in modern cricket^[1,8] [Figure 6]. MRI imaging protocol should include the ischial tuberosity to the knee to cover the hamstring tendon origin and insertion. The British Athletics Muscle Injury Classification is a commonly used classification for grading muscle injuries and estimating return to play.^[9]

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Figure 6:

Magnetic resonance imaging short-tau inversion recovery (a) coronal and (b) sagittal images respectively, in a cricketer with posterior thigh pain. These show edema with fluid signal intensity (yellow arrow) in the biceps femoris muscle with thickening and hyperintensity within its tendon (white arrow). British athletics muscle injury classification grade 2c injury.

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Tibial stress fractures and stress reactions occur commonly in bowlers, batsmen, and fielders, usually along the medial tibial cortex [Figure 7]. Imaging helps to evaluate the severity of these injuries and grade them, which helps the treating physician and physiotherapist estimate return to play. The Fredericson classification is commonly used to grade medial tibial stress injuries.^[10]

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Figure 7:

Magnetic resonance imaging short-tau inversion recovery (a) sagittal, (b) coronal, (c) and (d) axial images respectively, in a cricketer with pain in the right anteromedial leg. Marrow edema (white arrow) and subperiosteal edema (yellow arrow) in tibia with cortical linear hyperintensity (orange arrow). Fredericson grade 4b tibial stress injury (in this case a stress fracture).

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Patellar tendinopathy, iliotibial band friction syndrome, and chondral degeneration are overuse injuries of the knee seen in cricketers [Figure 8]. Knee ligament tears and meniscal injuries occur but are less common than in football. Most of the anterior cruciate ligament and meniscal injuries are reported to occur in fielding while diving to catch the ball.^[11] Knee collateral ligament injuries usually occur in bowlers when the knee is twisted on a fixed foot during bowling.^[12]

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Figure 8:

Cricketer with pain along the lateral aspect of the knee. Magnetic resonance imaging proton density fat sat (a) coronal and (b) axial images show edema (white arrow) in the soft tissues deep to the iliotibial band (yellow arrow). These findings indicate iliotibial band friction syndrome.

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Ankle ligament injuries also occur, along with anterolateral and posterior ankle impingements. Posterior ankle impingements are common in fast bowlers and can be associated with ankle synovitis, os trigonum disorders, and flexor hallucis longus tendinosis. Acute injuries are more common in the forefoot during sagittal movements, such as in bowling, while chronic overuse injuries and instability are more common in the hindfoot.^[1]