Individuals participating in sports and physical activity is becoming increasingly more common with the increasing awareness of its importance in maintaining a healthy lifestyle. With this comes an increase in sporting musculoskeletal injuries, some of which are traumatic, others resulting from a lack of acute adaptation to load, or chronic overload of musculoskeletal structures. These injuries can be minimised or avoided with early diagnosis’, appropriate load management and intervention.
For the primary musculoskeletal practitioner, clinical judgement in the determination of when to request medical imaging and the relevance of abnormal imaging findings when individuals present to us in clinic is of utter most importance.
Studies have found abnormal pathological changes on imaging in the asymptomatic or minimally symptomatic population. For instance, osteoarthritis, intervertebral disc protrusions and rotator cuff tears can occasionally be asymptomatic, as with age-related changes. Therefore, it is highly important for us practitioners to treat the patient and not the scan.
A study investigating intra-articular knee injury diagnosis accuracy with a physiotherapy physical examination against magnetic resonance imaging (MRI), found 70-80% accuracy of both methods. Additionally, some musculoskeletal injuries are managed the same, with or without medical imaging. Therefore, indications for requesting imaging for primary practice physiotherapists include:
1. Uncertainty of clinical diagnosis, in which management of the patient will be influenced;
2. Clinical red flags are present as such sinister or systemic abnormalities must be excluded;
3. Exact clinical diagnosis is known; however, extent of damage and complications are not clear;
4. Intervention has failed to make improvements and the reasons for this are unclear;
5. Objective evidence for documentation of progression and resolution is required.
If referring on for imaging the patient’s circumstances must be considered. For instance, the dose of ionising radiation the patient will be exposed to in the case of x-ray’s, CT scan and bone scans as these have the potential to be carcinogenic. Any contraindications for imaging such as pregnancy and the cost of the investigation both to the economy and the patient (ultrasound and x-ray verses magnetic resonance imaging).
Significant advancements in medical imaging techniques and technology has emerged over the last few decades, improving the ability to non-invasively determine specific anatomical structures as a source of pain, and assisting diagnosis of a musculoskeletal conditions for the primary practice physiotherapist. This however does not replace the benefits of an in-depth physical examination and the importance of treating the patient and not the image.