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

Abstract

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.