The interface between MSK radiology and musculoskeletal and sports medicine practice: Who takes clinical responsibility for the patient?

A novel approach to traditional clinical radiology presentations took place recently in Oxford. The British Institute of Musculoskeletal Medicine (BIMM) hosted a Spring Symposium attended by sports physicians, rheumatologists, general practitioners with a special interest (GPSIs), and radiologists with a special interest in musculoskeletal (MSK) problems. Given the enthusiasm of sports medicine physicians and other non-radiology trained physicians in the use of imaging to complement their diagnostic abilities and administer therapeutic agents, with an ever likely potential for ‘turf battles’, a lively interaction between radiologists and non-radiologists was assured. Speakers included distinguished consultants in the fields of radiology, MSK medicine, orthopaedics, and sports medicine from London, Salisbury, Birmingham, and Oxford.

The perennial problem for clinicians, outlined by Dr Grahame Brown (MSK physician) is the problem of making a diagnosis. He chose to put diagnosis in the widest context. Listening to the patient's story without interrogation, building a rapport to enable elicitation of all the thoughts, fears, and attitudes of the patient in the context of their own individual lives being the only real way of getting to the roots of the presenting symptoms. A thorough examination using palpation to identify tender tissues and dysfunction complements the history and builds a complete picture. Without this complete picture interpretation of normal and abnormal imaging findings remains a two dimensional approach.

This led on to a talk by Dr Philip Bell, consultant in sports and exercise medicine (SEM), outlining the essentials of sports medicine practice. Injury is often related to ‘what they do and how they do it’. High volume and repetitive training can result in abnormal imaging that simply reflects normal physiological changes, (a good example being the endurance athlete's heart which used to be interpreted as ventricular hypertrophy).

Diagnosis should be made clinically, imaging usually confirming what you know clinically. He pointed out the danger of uncertain clinical diagnosis and then going on an ‘imaging fishing trip’ which might throw up irrelevant findings and lead to unnecessary operations. Examples are asymptomatic soccer players with femoro-acetabular impingement (cam or pincer femoral heads) and small labral tears, and asymptomatic shoulders in tennis players with rotator cuff tears.

By contrast, he cited examples of pathology where imaging may be normal or undercall the pathology. His advice was to ‘stick to your guns’ and pursue the diagnosis rather than being put off the scent. Myofascial dysfunction is a common cause of pain in sportsmen and never shows any abnormal imaging.

He emphasized the importance of knowing your sport, using the example of ballet dancers who are all hypermobile and often loading joints at end-range position which requires adaptive changes normal for this population. From his long experience with elite tennis players whose server arm often gets tight in the posterior capsule he asserted that GIRD (glenohumeral internal rotation deficit) is almost universal. It is a clinical, not imaging, diagnosis but may lead on to pathological changes (‘peel back’ on arthroscopy).

Dr Richard Smith, consultant rheumatologist from Salisbury explained the different ways to image pain, with particular reference to functional magnetic resonance imaging (MRI) brain studies. He reported on a recent collective of four studies which showed that functional MRI (which measures change in oxygenation of a region due to increased blood flow) could reliably distinguish between pain due to noxious heat versus warmth, heat pain versus social pain, and demonstrate diminution of physical pain with remifentanil.¹ In other words there is a way of objectively measuring pain using the neurological ‘signature’. Clinically we rely only on subjective measures.

He also reported on the use of MR spectroscopy in patients who fitted the modern ACR (American College of Rheumatology) criteria for fibromyalgia (FM) which showed abnormal metabolite build up in the hippocampus region. Other studies using SPECT (single photon emission computerized tomography) scans and fMRI support the theory that there is abnormal central pain processing in FM.²

Consultant MSK and SEM radiologist Dr Gina Allen from Oxford presented some guidelines on how we might decide which imaging findings were relevant. She covered a wide range of injuries demonstrating which imaging modalities are best for specific types of injury; dynamic ultrasound is useful for determining the cause of painful clicks around the hip joint, and also for the response of muscle injury to contraction and demonstrating the degree of rupture.

She summarized the relative importance of ultrasound versus MRI in acute muscle injuries: MRI is especially valuable on day 1, whereas ultrasound improves in usefulness thereafter.

Dr David Wilson (St Luke's Radiology, Oxford) discussed how changes in technology may alter management over the next few years, with particular reference to the smaller MRI and computerized tomography (CT) systems. He showed examples of extremity CT scan which is relatively low dose and cheap and enables identification of more subtle bony injury such as might occur in trauma to the foot and ankle. He also showed how modern ultrasound scanners enhance diagnosis in difficult soft tissue injury cases due to their superior resolution (better than MRI), their ability to scan dynamically and demonstrate increased blood flow (neovascular infiltration) where there is neurogenic inflammation.

The thorny topics of image-guided interventions, in particular, the use of fluoroscopy and ultrasound by radiologists and non-radiologists was presented by specialists in these fields. Dr Declan Johnson, interventional neuroradiologist from St George's Hospital, London proclaimed the advantages of CT guidance for spinal injections such as facet and sacroiliac injections. Modern low-dose CT protocols enable the radiation dosage to approximate the significantly lower radiation dosage of fluoroscopically-guided injections. However transforaminal injections under CT with contrast enhancement although made easy with axial imaging by CT did not satisfactorily resolve the worrying risk of medication spreading in small vessels such as radicular arteries to the anterior spinal artery and in some cases causing quadriplegia and even death in cervical spine cases. Dr John Tanner, president of BIMM, showed illustrations of contrast medium (and hence of medication with particulate steroid) flowing outside the limited field of view afforded by CT and into vertebral or radicular vessels in the cervical spine. He said that when performing such injections for benign pain conditions safety must be prioritized above ease of needle placement. It is safer to use non-particulate steroids for transforaminal injections in the cervical spine.

A review of the literature for the evidence for ultrasound-guided injections was presented by Dr Marian O'Reilly and hotly debated by MSK physicians in attendance, who have considerable experience in clinically guided interventions. The jury is still out with regard to satisfactory evidence for superior efficacy of ultrasound-guided injections in common joint and soft tissue injection.

Dr Adam Mitchell, consultant radiologist from the Chelsea and Westminster Hospital, London discussed several case scenarios where clinical management was less than satisfactory due to confused clinical responsibility. In conclusion, it was agreed that a spirit of understanding and co-operation between clinicians and radiologists is paramount in the interests of patient care. We look forward to further close collaboration between radiologists and physicians managing patients and sports people in the future.