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A Revolution in Diagnostic Imaging

Paul W. Mamula, PhD


In November 1966, Sandy Koufax, the star left-handed pitcher of the Los Angeles Dodgers, retired after spending his final season coping with traumatic arthritis in his elbow, the compounded effects of a sliding injury to his pitching arm the previous season and 12 years of hard throwing.1 Had his career begun a few years later, he might have been able to benefit from the advances in diagnostic imaging and treatment that were introduced at that time. Modern arthroscopy and computed tomography (CT) did not become available until the mid 1970s,2 and the first elbow reconstruction was done by Frank Jobe, MD, about 10 years after Koufax retired.1 Arthroscopy was first used as a diagnostic tool, but it later became a surgical tool, affecting treatment of knees, then, later, shoulders. Since 1973, when The Physician and Sportsmedicine was launched, we have witnessed a revolution in diagnostic imaging and are continuing to see an evolution of modalities.

The new imaging techniques "have revolutionized sports medicine diagnostics, and the techniques are continuing to be refined," says Joseph R. Martire, MD, assistant professor of radiology at Johns Hopkins University School of Medicine and cofounder of the Sports Medicine Center at Union Memorial Hospital in Baltimore. The advent of new techniques has had a dramatic influence on physicians and active patients. Up to the early 1970s, about the only tools available for imaging injury sites were radiography, fluoroscopy, and tomography.2 Today, physicians can rely on many technologies for diagnosing musculoskeletal injuries—magnetic resonance imaging (MRI), CT, bone scintigraphy, and other modalities—that have dramatically improved how injuries are assessed and, in turn, treated.

The Imaging Revolution

Physicians who finished their training in the 1970s have seen these tremendous changes.

"When I finished my training in 1975, there were no MR images and no full-body CT scans—only partial CT scans. Bone scans were about the only technique available in nuclear medicine for imaging these kinds of injuries," says Conrad E. Nagle, MD, chief of nuclear medicine at William Beaumont Hospital in Troy, Michigan. Over the years the development and introduction of new technologies have improved treatment and taken much of the guesswork out of therapy. "For many conditions," Nagle says, "the treatment was once limited to 'wait and see' or perform surgery; few alternatives were offered. Now with the widespread availability and noninvasive nature of bone scans, MRI, ultrasound, and CT, earlier detecton of injury is possible." Thus, treatment can be tailored to patient injury and level of activity (professional, elite, or recreational athlete). Imaging today is remarkably sensitive and can pinpoint sites of injury, a stark contrast to what was possible 30 years ago.

The Impact on Active Patients, Physicians, and Therapy

While the new technologies have eliminated some of the diagnostic headaches for physicians, the modalities have generated different problems. Now, patients want a definitive answer so that they can get back to their activity sooner, and they may pressure physicians for a particular test. The technology's sensitivity can also create other dilemmas. "Sometimes a test such as a bone scan can tell the physician that the injury is most probably a stress injury, for example, but there remains a certain statistical possibility that it might be something else," Nagle says. "A CT scan may be ordered to rule out that other possible condition or conditions." Once the physician is sure that the diagnosis is correct, appropriate treatment can be recommended." Not doing so may mean that the suspected stress injury is actually something else and might provoke the wrong treatment, opening the possibility for lawsuits.

Although concerns about provider payment are not usually a problem for the professional or elite athlete, some providers might question use of the technology under some circumstances. In such instances, physicians may have to decide what test to use partly based on cost. Although imaging is expensive, these modalities can be used to confirm a suspected cause, and then serve as a "surgical roadmap" for treatment. A good history, a thorough physical exam, and plain x-rays can catch common problems, but the next step depends on factors such as patient activity, changes in training, and patient goals, Martire says. "When imaging is needed, having it done by specialists with an interest in sports medicine is important," he adds.

For patients, the technology has offered improvements in treatment. CT scans can be converted into three-dimensional images that help surgeons.3 For patients such as those who have back pain from years of heavy labor or repetitive movement, imaging can help determine optimal placement of rods.3 In others, it can assess whether a stent is suitable in a particular artery. For active patients with fractures at the tibial plateau, visualizing fragments can help tailor repair and speed recovery. A growing concern among physicians is the use of such newer modalities by the "worried well." Because imaging services are available for a fee, some patients pay for their own imaging without a physician's order. While physicians are getting more questions about using CT scans for health purposes, they don't routinely endorse patients' getting them without a physician's recommendation.3

James G. Garrick, MD, an orthopedic surgeon at the Center for Sports Medicine at St Francis Memorial Hospital in San Francisco, points out that reliance on CT and MRI has caused a decline in the art of history taking and performance of a complete examination. Advanced diagnostics such as MRI may not mean much for some patients. Garrick notes that nearly all MRIs of the shoulder show abnormalities, but many of these have little clinical importance for the patient. Garrick does acknowledge that MRI offers some benefits. "I think these techniques might help explain some of the later problems associated with injuries such as anterior cruciate ligament sprains," he says. "The bone 'bruises' seen on MRI may be the precursors of the cartilage defects that we so frequently see."

The Continuing Imaging Revolution

Even though dramatic changes in diagnostic imaging have taken place, newer technologies continue to be developed. These include the hybrid imaging technologies such as devices that combine bone scans and CT. These devices couple refined sensitivity with the components of simultaneous imaging. "This capability can help us understand why certain structures are more likely to be injured. We can detect delayed muscle soreness and learn why that muscle became sore. In the case of tibial plateau fractures, the imaging can allow the surgeons to implement the most effective repair," Martire says.

Major new areas of research for diagnostics4 and musculoskeletal injuries5 that will guide the evolution of new technology include molecular imaging to detect cellular and subcellular molecular events and image-guided therapies that incorporate advances in image fusion-integration capabilities. Combined technologies that use a single machine to generate scans simultaneously then incorporate them into a three-dimensional image represent the cutting edge of diagnostics. These innovations will allow more detailed views of tissues and present earlier opportunities for identifying disorders, guiding interventions, and monitoring the effects of therapy.4 For orthopedics, image analysis, three-dimensional reconstruction, and telemetry will aid transmitting information into the operating room. "The newest development will be the gaining of additional experience so that the clinical importance of the various 'abnormalities' can be ascertained," Garrick says. Continuing improvement should make the next few decades exciting.


  1. Leavy J: Sandy Koufax: A Lefty's Legacy. New York City, HarperCollins, 2002, pp 155-157
  2. Martire JR, Levinsohn EM: Imaging of Athletic Injuries: A Multimodality Approach. New York City, McGraw-Hill, 1992
  3. Burcum J, Lerner M: The body transparent. A special report: medical imaging. Minneapolis Star-Tribune, December 15, 2002, section S, pp 1-4
  4. Tempany CMC, McNeil BJ: Advances in biomedical imaging. JAMA 2001;285(5):562-567
  5. Boskey AL: Musculoskeletal disorders and orthopedic conditions. JAMA 2001;285(5):619-623

Dr Mamula is an associate editor of The Physician and Sportsmedicine.