Imaging in sport: beyond diagnosis, a tool for prevention and performance optimization

“The role and importance of imaging is changing. It used to be just for diagnosis, but now it’s widely used for prevention”, explains Minafra. “By the time we make a diagnosis, it’s already a little too late. The goal is to prevent injuries,” he adds. For instance, imaging technologies can detect minor joint instabilities that may lead to long-term issues, as well as hidden functional overloads that often remain asymptomatic in athletes. “However, the equipment must be used by qualified professionals,” warns Minafra. “They are essential for understanding what to look for and how to correctly interpret the images so that informed decisions can be made”.

Minafra offers a concrete example: “When we compare the Achilles tendon of a professional athlete to that of the average person, it’s usually thicker and more frayed. That simply means it has adapted to exertion,” not that it requires treatment or that the athlete should stop training.

That’s why “we don’t rely on imaging alone. We also conduct functional testing, strength assessments and movement analysis. When interpreting images, specific criteria help distinguish between findings that appear pathological but are adaptive. There is a fine line between adaptation and pathology,” adds Minafra.

Mozzone confirms: “Ultrasound and MRI are increasingly used in soccer, with dedicated equipment and trained practitioners. In the past, their use was less common, and the level of quality and professionalism was lower. Today, sports medicine physicians who work with athletes are also trained sonographers.”

This shift allows for more accurate diagnoses and more effective prevention strategies, as Mozzone also explains: “In this way, we can also detect early symptoms in athletes. For example, we can prevent overload from leading to injury or prevent tendinopathy from developing into a chronic condition.”

A third area of development is the use of imaging to optimize athletic performance. “Yes, functional imaging helps us correct the athlete’s movement patterns,” Minafra explains. In addition to using analysis software, teams now employ radiological imaging during motion or video recordings to analyze athletes in action. 

For example, imaging is a valuable tool in preventing one of the most common (and often serious) injuries in soccer: ACL injuries. These injuries are frequently caused by technical or postural errors, which can be identified through imaging.

Given these advantages, it is no surprise that the use of imaging for preventive and performance-related purposes has become prevalent “among all Serie A league teams, albeit with different technologies,” as Minafra explains.

Overall, the data indicate a significant increase in the use of imaging techniques for the diagnosis of injuries in professional athletes in recent years. Data collected by the Radiological Society of North America during high-level sporting events revealed that imaging was used to diagnose sports injuries in 6.4% of athletes at the 2016 Summer Olympics.

During the Tokyo 2020 Olympic Games, diagnostic imaging continued to play a pivotal role in managing athlete injuries, reinforcing a trend observed in previous editions of the Olympic Games. A study published in 2022 in BMC Musculoskeletal Disorders analyzed the use of magnetic resonance imaging (MRI) and X-rays at the Olympic Village Polyclinic, where 567 MRI scans and 352 X-rays were performed.

The study reported that 29 athletes were diagnosed with 42 stress-related bone injuries, including 4 stress fractures and 38 stress reactions, with a higher prevalence in females and those competing in athletic events.

While the incidence of this specific injury was relatively low – affecting approximately 0.26% of athletes - it is important to note that 72% of the affected athletes had already exhibited symptoms before arriving at the Olympic Village. This underscores the critical role of early imaging in preventing relapses and optimizing performance. When comparing the two Olympic editions, it appears that imaging use has become more strategic, with a targeted approach increasingly guided by clinical data - rather than reflecting a decrease in injury incidence. The strategic importance of imaging becomes evident in both scenarios, extending beyond diagnosis to include recovery planning and preventing more severe injuries through its capacity to detect early indications of bone or muscle overload.

One of the most recent advancements in ultrasound application is ultrasound-guided physiotherapy, commonly referred to in the literature as RUSI (Rehabilitative Ultrasound Imaging). This technique is used by physical therapists to assess muscle and soft tissue morphology and function during exercise and physical activity. The integration of ultrasound into clinical physiotherapy practice enhances objective examination by providing detailed, real-time information on tissue status. This, in turn, supports the identification of cases that may require medical referral and allows for more accurate parameterization of both exercise prescription and manual therapy interventions.

Several studies suggest that patients perceive the use of ultrasound for musculoskeletal conditions as a positive experience, which increases their compliance with treatment. This shows how imaging is becoming increasingly integrated into all phases of the management of athletes - from diagnosis to rehabilitation.

This trend has advanced in parallel with significant technological progress.

Basically, resolution quality is continuously improving: “We can now see even the tiniest details in MRIs or ultrasounds,” says Minafra. Equipment is also becoming increasingly portable and accessible.

“Portable ultrasound scanners have now become a companion, especially during summer training sessions in the mountains. We rely on them to make decisions about minor issues. We can’t go to the hospital for every small problem, especially if it’s far away,” he explains.

The American Medical Society for Sports Medicine officially recognized sports ultrasound as a common practice among sports medicine physicians, aiming to enhance both diagnostic and procedural accuracy. Updated in 2022, this consensus statement highlights the evolution of ultrasound from a complementary tool to a key component in the evaluation of athletes.

Low-field MRI is also becoming more common and practical: “We use it for joint and motion imaging. It’s more sustainable – using less energy – and more accessible than conventional MRI. It’s also suitable for claustrophobic patients.” Minafra adds.

“We’re using dynamic MRI more frequently,” confirms Mozzone, “although it still isn’t widely adopted.”

The two practitioners also highlight the potential of ultrasound with elastosonography, a technology used to detect muscle fatigue. This refers to the ability of the muscle to adapt elastically to exertion.   

Minafra also uses thermography, “It allows us to assess the body’s heat dissipation. Temperature asymmetries greater than 0.5°C can indicate potential issues, particularly in the feet or legs”. He adds that, although not yet widely adopted among Serie A teams, the technology is gaining traction, especially following its earlier uptake in Spain.

In general, functional imaging in motion is becoming more widely used. “It helps with the more insidious aspects of muscle recovery. Sometimes it’s hard to determine whether a muscle has fully recovered functionally, even if it appears structurally sound,” says Minafra. Real-time ultrasound during movement offers a more complete picture, enabling practitioners to adjust external loads and reduce the risk of relapse. The same approach applies to recovery from ACL injuries.

Dynamic imaging is also used for diagnosis. “Dynamic MRI shows meniscal instabilities that aren’t visible in static mode,” Mozzone explains. “Rectus-adductor syndrome (pubalgia) requires a dynamic ultrasound to detect abdominal wall laxity and the presence of hernias that are not visible at rest,” he adds. In these cases, the examination is performed with the patient’s legs raised. “All you need is a high-resolution ultrasound scanner,” he notes.

Artificial intelligence is playing an increasingly prominent role in imaging, just as it is across many medical disciplines. According to Mozzone and Minafra, AI-enabled systems can enhance image quality while significantly reducing scan time. “This is especially important for professional athletes. Thanks to AI, a knee MRI can now be completed in ten minutes instead of thirty,” says Mozzone.

But again, what makes the difference is the right combination of technological evolution and human expertise, which must go hand in hand. “AI won’t replace radiologists, but those who don’t use it may be replaced,” says Minafra.

AI will continue to evolve; at the same time, teams will need to place more and more value on specialized skills. AI is helpful, but there is still a need for “a practitioner who specializes in the musculoskeletal area being analyzed, to interpret the image, but also to capture it in the right way,” Minafra points out.  

AI is also becoming increasingly popular as a means of preventing sports injuries and optimizing training programs, especially in Spain and Anglo-Saxon countries. AI-based predictive systems can analyze large volumes of data–including physiological parameters, workload, movement biomechanics, and injury history – to identify subtle patterns that signal increased injury risk or the need to adjust training loads.

A study published in Sensors (2024) found that the use of these systems was associated with a 50% reduction in muscle injuries in clubs that systematically implemented them.

A 2024 analysis of a sample of 500 athletes found that several machine learning algorithms–including Random Forest, Gradient Boosting, convolutional neural networks (CNN), and recurrent neural networks (RNN)–achieved a maximum predictive accuracy of 92% in predicting injuries based on load and performance data (Physical Education Journal, 2024). Conducted in partnership with the FC Barcelona Innovation Hub, the study shows how the most advanced clubs are strategically investing in predictive technologies.

Another promising initiative is SoccerGuard, a framework developed to predict injuries in women’s soccer teams based on GPS data, training loads, and medical records. The results, presented in arXiv (2024), show that well-trained models can predict injuries with above-average accuracy, making them a valuable decision-support tool for medical and technical staff.

However, challenges remain. Among them is data quality: the accuracy of predictive models depends on the consistency and granularity of the collected data. In addition, many algorithms still function as “black boxes”, making it difficult for physicians and trainers to fully understand the reasoning behind a prognostic statement. As a result, effective implementation requires close collaboration between physiologists, data engineers, and clinical staff. Once again, the human-technology partnership proves essential.

AI will play a role in the future of sports medicine. But it will also be important to make a number of less disruptive, incremental advances over the next few years, such as “stabilizing the operating protocols of functional imaging, which until recently has been at the forefront of innovation,” Minafra says.

“We will have better, more sustainable, more portable equipment,” he predicts.

Telediagnosis will also become more common: “We’re already using it, but eventually we’ll have a network of specialists who can be consulted remotely, possibly even in real-time,” Minafra adds.

“In the future, athlete care will improve across the board—not just because of better tools, but also due to increasing specialization and awareness among professionals in the field,” concludes Mozzone.