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Understanding MRI: Magnetic Resonance Imaging

by Lesley Ngwa
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You could be forgiven for missing that the qualifying matches for a big youth football event—the Under-17 Africa Cup of Nations in April in Algeria—are underway right now, what with the African Nations Championship in Algeria again taking centre stage all week. But then you might miss the latest “doping” scandal playing out in African football headlines: More than half of Cameroon’s U-17 (under age 17) team has been side-lined based on lab scans.

Yet the dismissal is not over a traditional malfeasance such as performance-enhancing chemicals or hormonal supplements. It is about age fraud. Clinical testing suggested that these players were actually older than 17.

As a result, 21 young male athletes from Cameroon were deemed ineligible to participate, the Central African Football Federations’ Union (UNIFFAC) told kick442.

Another 11 players are said to have been caught by Magnetic Resonance Imaging (MRI) screening that initially saw 21 of the country’s original 30-strong squad for this month’s regional African Cup of Nations qualifiers sent home, giving manager Jean Pierre Fiala barely a week to bring in further reinforcements.

Cameroon host Congo, and Central African Republic for the Central African Football Federations’ Union (UNIFFAC) qualifiers between January 12 and 24, with two teams progressing to April’s Under-17 Nations Cup in Algeria.

The decision to bar these Cameroonian players from the tournament was based on a procedure that FIFA, football’s international governing body, put in place in the 2009 Under-17 World Cup, which took place in Nigeria. It urged youth players to submit to magnetic resonance imaging (MRI) scans of their wrists in an attempt to determine their age eligibility. (CAF, which is under the auspices of FIFA, requires all players to submit to the scans as part of the regulations for the U-17 Africa Cup of Nations.)
Admirably, the protocol is designed to prevent older, stronger players from entering youth tournaments in settings where birth certificates or other ways of verifying age may be absent.

According to FIFA, wrist MRIs and the bone growth they show can indicate if a player is older than 17. Yet a deeper dive into the study behind this decision reveals that its foundation is shaky at best.

MRI scans can determine whether a player is below 17 with 99 per cent accuracy, experts say, as they can show whether he or she has stopped growing — which usually happens after 17.

“While it is the responsibility of each member association to ensure that their players meet the age requirements, FIFA has decided to conduct magnetic resonance imaging of the wrist at its U-17 competitions,” said a FIFA spokesperson.

Understanding MRI

FIFA rolled out this protocol based on a study conducted by its Medical Assessment and Research Centre and published in the British Journal of Sports Medicine. For that work, researchers performed wrist MRIs (deemed more ethical than exposing the subjects to x-ray radiation) on about 500 young men between the ages of 14 and 19. The teens all hailed from Switzerland, Malaysia, Algeria or Argentina. The researchers then categorized each participant’s wrist bone development into one of six stages based on the fusion of his distal radius, a bone area near the wrist joint. Stage 6 represented complete fusion and stage 1 represented no fusion. Citing this work, FIFA says that if the MRI shows complete fusion of a player’s wrist, it is 99 per cent certain that the player is over 17 (spoiler alert: that’s not really true).

Wrist bone development certainly does change during adolescence. Before puberty the human body cranks out cells that help produce new cartilage along the ends of bones. These areas of the bone, known as growth plates, are eventually converted into bone material, which helps the bones lengthen. Yet as teenagers, both males and females start producing more oestrogen, which slows that cellular production process—and their growth plate cartilage subsequently gets thinner and thinner until some of the bones in that area fuse together, and the growth plates close and are replaced by solid bone. (That’s why wrist scans are sometimes used alongside those of the fingers, in tandem with other biological information, to estimate a growing child’s eventual height.) The exact timing of this fusion, however, varies a lot between individuals. For example, FIFA’s own researchers said in an analysis published that using this same age cut-off for female athletes is extremely problematic because many girls already had complete fusion before age 17.

Failing MRI test doesn’t equate to age cheating

In FIFA’s citing of the foundational MRI study for boys, however, its major mistake lies in applying these population-level statistics to individual athletes. A closer examination of the full data shows that the actual wrist bone growth stages can occur at a wide range of ages. Among 16-year-olds, for example, roughly the same number of kids were at stages 1, 3, 4 and 5, representing a spectrum of growth at that age. “There is so much overlap that you may have a person who is 18 who could have only minimal fusion to complete fusion, and there are people who are already fused going from ages 20 to 16,” says Vicente Gilsanz, a professor of radiology and pediatrics at the University of Southern California. Although only one player in the 16-year age group was graded as completely fused (stage 6), the standard deviation in that grouping is also pretty telling.

The reason standard deviation is so illuminating comes down to basic statistics. The average age for complete fusion, according to the analysis, is 18.3 years. Yet there might be some variation in that fusion timing, and that possibility is represented by standard deviation calculated in the analysis—0.9 years. Anyone setting such important guidelines should typically include two standard deviations in either direction from the average age to capture most of that variation, says Frank Rauch, a professor of pediatrics who specializes in bone health at McGill University.

Here, two standard deviations from that average age of complete fusion would include ages 16 to 20. “Maybe people are not concerned about unfairly excluding kids from competition,” Rauch says, “but that’s the inevitable problem.”

Meanwhile, subsequent work also throws more cold water on the science of these wrist scans: One study on 86 young male Ghanaian players concluded, “There was no significant correlation between the chronological age and the degree of fusion.” Another analysis that similarly employed wrist scans among young players found that three supposed 14-year-old male football players had stage 5 or stage 6 fusion. In that analysis, too, the authors similarly noted, “no correlation was observed between age category and grade of fusion.” But in both studies the authors dismissed the results—suggesting perhaps players were simply not aware of their real ages.
There are also genetic and environmental factors to consider before applying this study’s findings to the real world. The analysis underpinning FIFA’s age regulation does include some individuals from Algeria (which is in North Africa), yet it does not include anyone from sub-Saharan Africa, where this ruling has been applied before—and is again now. Very little puberty research is focused on the sub-Saharan region, so it is difficult to pinpoint information about the onset and tempo of puberty in Cameroon. But scientists have uncovered variation elsewhere. Multiple studies have shown that kids embark on puberty at different times based on factors including nutrition, environment and ethnic background. Puberty in African-American girls who grow up in the U.S. begins roughly a year earlier, on average, than among white girls, for example.

Ultimately, there is no known fool proof, scientific test that will allow doctors—or sports regulators—to determine an individual’s age. The science suggests that applying a lone wrist MRI test to make such determinations is inappropriate at best and potentially harmful at worst. Political leaders and regulators searching for age tests in other settings—such as classifying immigrants seeking asylum (because different rules apply for minors and adults)—could potentially look to this type of age cut-off test, too, with troubling results. Right now “people aren’t trying to use magnetic resonance imaging [to classify the age of refugees] but they are using x-ray imaging to look at bone age and make a determination as to whether they are children or not,” says Babette Zemel, a pediatrics professor focused on child growth and development at The Children’s Hospital of Philadelphia. “Looking at the bones can give you a good idea if one child is skeletally more mature, but it is insufficient for determining whether or not a child should be permitted to be on a sports team or claim asylum status because it doesn’t tell you about their chronological age.”

The way forward

In football there are established age‐related tournaments for males and females, to guarantee equal chances within the game for all the different age groups. Over the years, the tournaments have gained momentum and popularity, particularly the under‐17 competitions. Unfortunately, there has been some suspicion that the biological age of the participating players might be older than the documented age as stated by the passport or birth certificates used to determine the eligibility of the individual. This situation is aggravated by the fact that in some Asian and African countries registration at birth is not compulsory. Thus, reliable methods for proper age estimation are required. Discrepancies in age lead to unequal chances and are against the spirit of the game and, of course, “fair play”. Age, experience, body size and stage of puberty contribute considerably in different combinations to the variance of some football skills such as dribbling with a pass, ball control with the body and shooting accuracy.

Also, players with a greater relative (or possibly false lower) age are more likely to be identified as “talented” because of the likely physical advantages they have over their “younger” peers.

Standard radiographs are also used medico-legally to determine age in a court of law. Their use is based on a court order by a judge who allows the use of the limited radiation to obtain the images needed to determine the skeletal age.

The International Atomic Energy Agency regulates the use and possible abuse of x rays under the title “International basic safety standards for protection against ionizing radiation and for safety of radiation sources”.

Thus, in sports the use of x rays (a radiation exposure) to determine players of over age is not allowed by a court of law as the action does not amount to criminal action.

As the screening of football populations by using radiographic examination cannot be justified, other methods such as ultrasound have been investigated; however, such an x ray‐free examination method could be used in all sports in case of discrepancies or suspicion that a date of birth presented is inappropriate. This might be of interest not only to football but also to the entire sports community and the International Olympic Committee, where age determines competing categories, as well as for paediatricians, when dealing with endocrinological or other disorders, and also for courts, when dealing with criminal offence by under‐aged persons.

(Excerpts courtesy of Fifa.com)

(Excerpts courtesy of case.edu/med/neurology)

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