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ABSTRACT
Purpose: The aim of this study was to develop evidence-based diagnostic imaging practice guidelines to assist
chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging of lower
extremity disorders.
Methods: A comprehensive search of the English and French language literature was conducted using a
combination of subject headings and keywords. The quality of the citations was assessed using the Quality of
Diagnostic Accuracy Studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the
Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for
Imaging (Radiation Protection 118) coordinated by the European Commission served as the initial template. The first
draft was sent for external review. A Delphi panel composed of international experts on the topic of musculoskeletal
disorders in chiropractic radiology, clinical sciences, and research were invited to review and propose
recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer reviewed by
field chiropractors, and by chiropractic and medical specialists. Recommendations were graded according to the
strength of the evidence.
Results: Recommendations for diagnostic imaging guidelines of adult lower extremity disorders are provided,
supported by more than 174 primary and secondary citations. Except for trauma, the overall quality of available
literature is low. On average, 57 Delphi panelists completed 1 of 2 rounds, reaching more than 83% agreement
on all 56 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of
guidelines, and implementation feasibility.
Conclusions: The guidelines are intended to be used in conjunction with sound clinical judgment and experience and
should be updated regularly. Dissemination and implementation strategies are discussed. Future research is needed to
validate their content. (J Manipulative Physiol Ther 2007;30:684-717)
Key Indexing Terms: Practice Guideline; Guideline; Diagnostic Imaging; Radiology, Diagnostic X-ray;
Radiography; Adult; Musculoskeletal System; Pain; Lower Extremity; Hip; Knee; Ankle; Foot; Trauma
REPORTING OF TOPICS INCLUDED IN THE DEVELOPMENT OF imaging guidelines. This initial review led to a research
THE DIAGNOSTIC IMAGING PRACTICE GUIDELINES
1 project divided into 9 phases: (1) literature search, (2)
independent literature assessment, (3) guideline develop-
An initial literature review considered 10 clinical ment specific recommendations, (4) first external review, (5)
questions pertaining to imaging of musculoskeletal condi- consensus panel (modified Delphi), (6) public Web site, (7)
tions to evaluate the pertinence of developing diagnostic second external review, (8) final draft and grading of the
recommendations, and (9) dissemination and implementa-
a tion. Details of this study are published elsewhere.2
Professor, Chiropractic Department, Universit du Qubec
Trois-Rivires. Focus
b
Professor of Radiology, New York Chiropractic College;
Adjunct Professor, D'Youville College, Buffalo, New York. These diagnostic imaging guidelines concern adult
c
Professor, Canadian Memorial Chiropractic College. musculoskeletal disorders of the lower extremities where
Submit requests for reprints to: Bussires, Andr, dpartement conventional radiography and specialized imaging studies
chiropratique, Universit du Qubec Trois-Rivires, C.P. 500, are deemed useful for diagnostic purposes.
Trois-Rivires, Qubec, Canada G9A 5H7
(e-mail: [email protected]). Objectives
Paper submitted July 15, 2007; in revised form September 12, These proposed guidelines are intended to reduce unneces-
2007; accepted October 14, 2007.
0161-4754/$32.00 sary radiation exposure and the use of specialized imaging
Copyright 2007 by National University of Health Sciences. studies, increase examination precision, and decrease health
doi:10.1016/j.jmpt.2007.10.004 care costsall without compromising quality of care. The
684
Journal of Manipulative and Physiological Therapeutics Bussires et al 685
Volume 30, Number 9 Diagnostic Imaging Lower Extremity Disorders
reasons for developing these guidelines include assisting cur- member reviewed all documents and provided comments
rent and future health care providers to make appropriate use of and suggestions.
imaging studies, providing indications for the need of imaging
studies according to current literature and expert consensus, and Stakeholders and Editorial Independence
assisting in optimizing the use of limited available resources. Pre-release Review. Before the release of the guidelines, the
reliability of proposed recommendations was tested on
Target Users/Setting specialists both in chiropractic and in medicine as well as on
Intended users of the guidelines are chiropractors and field chiropractors.
other primary health care providers prescribing diagnostic Potential Conflict of Interest. The research team involved in the
imaging studies. The setting in which these guidelines may development of these guidelines declares no existing or
be used include private clinics, outpatient clinics, and potential conflict of interest. No investigators have received,
hospital emergency departments. nor will receive, any personal financial benefits or derive any
salary from this project.
Target Population Funding Sources/Sponsors.
The patient population eligible for guideline recommenda- 1. Canadian Memorial Chiropractic College Post Gradu-
tions are adult patients presenting with musculoskeletal ate Education and Research (2005)
disorders of the lower extremities. Children and pregnant 2. National Institutes of Health student grant (2006)
patients are excluded from these guideline recommendations. 3. Canadian Chiropractic Protective Association (2006)
Developers Updating/Revision
The proposed guidelines are developed from the results of The literature review and the guidelines should be
9 distinct phases overseen by a research team composed of the updated every 2 to 3 years.
3 investigators with postgraduate education from 3 indepen-
dent teaching institutions. The guidelines were further Potential Benefits and Harm
developed and peer reviewed by more than 60 chiropractic
These include selection of appropriate radiologic imaging
clinicians, academics, researchers, and a group of physicians.
procedures for evaluation of patients with musculoskeletal
disorders of the lower extremities; and decreased unneces-
Evidence Collection
sary ionizing radiation exposure, decreased costs, and
Electronic searches in English and French language
improved accessibility.
literature occurred, and cross-references were repeated on 3
different occasions between 2003 and 2006.
Dissemination/Implementation Considerations
Methods for Synthesizing Evidence Means of dissemination include publication; application
to the National Guideline Clearinghouse; posting of the
1. Literature search and Independent literature assessment
of spinal disorders: Quality of Diagnostic Accuracy electronic document on various Web sites (malpractice
insurance carriers, outpatient teaching clinics); educational
Studies (QUADAS),3 Appraisal of Guidelines Research
intervention strategies (e-learning, community pilot studies);
and Evaluation (AGREE),4 and Stroke Prevention and
referral guidelines, reinforced by request checking and
Educational Awareness Diffusion (SPREAD).5
clinical management algorithms; promotion by national,
2. Initial draft. Template based on European Commission
provincial, and state organizations; and conferences.
classification (2001).6
3. Expert consensus. A 2-round modified Delphi process was
used to generate consensus among an international panel
Definitions, Patient Presentations, Recommendations, and Rationale
of more than 60 experts in musculoskeletal disorders. These topics are integral parts of each one of the three
diagnostic imaging guidelines: lower extremity disorders,
Recommendation Grading Criteria upper extremity disorders, and spine disorders. Results of the
9 phases of the research project are published elsewhere in
The evaluation tool used was designed by the Scottish
Intercollegiate Guidelines Network (SIGN) and adapted by this issue of the journal.2
the Stroke Prevention and Educational Awareness Diffusion
(SPREAD group).5,7 PRELIMINARY CONSIDERATIONS AND DISCLAIMER
What is the Role of These Guidelines?
Patient Preferences: Condition-Specific Imaging Guidelines These evidence-based diagnostic imaging practice guide-
Integral to evidence-based health care, decisions regarding lines are intended to assist primary care providers and
the use of imaging studies should be based on the best students in decision making regarding the appropriate use of
available evidence, and the experience and judgment of the diagnostic imaging for specific clinical presentations. The
clinician, while considering patient preference. A public guidelines are intended to be used in conjunction with sound
686 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Lower Extremity Disorders November/December 2007
clinical judgment and experience. For example, other special involves continuously and systematically searching, apprais-
circumstances for radiographic imaging studies may include: ing, and incorporating contemporaneous research findings
patient unable to give a reliable history, crippling cancer into clinical practice. The overall goal is improving patient
phobia focused on back pain, need for immediate decision care through life-long learning.12,13
about career or athletic future or legal evaluation, history of
significant radiographic abnormalities elsewhere reported to Potential Disagreements
patient but no films or reliable report reasonably available, There are several reasons for disagreement within a
and history of finding from other study (eg, nuclear medicine guideline development group. These include differences in
or imaging of the pelvis) that requires radiograph for interpretation of the research literature, differences in personal
correlation.8 Application of these guidelines should help experience, and different perceptions of the inherent risks and
avoid unnecessary radiographs, increase examination preci- benefits of a procedure.14 Divergent or competing guidelines
sion, and decrease health care costs without compromising on similar topics serve only to further confuse and frustrate
the quality of care. practitioners.15 In addition, the continued lack of unity among
The descriptions of clinical presentations and proposed chiropractors hinders growth of the profession by limiting
clinical diagnostic criteria, the recommendations for imaging integration and cooperation within the greater health care
studies, and the comments provided throughout this article are system. Readers of any guidelines are advised to critically
a synthesis of the vast body of literature consulted before and evaluate the methods used as well as the content of the
during the various phases of this research project. Where the recommendations before adopting them for use in practice.16
literature was found to be of poor quality or absent, consensus
based on expert opinion was used. Although the investigators Standard Patient Management Activities
and collaborators carefully searched for all relevant articles, it Standard patient management activities, including diagnos-
is probable that some have been missed. Furthermore, as many tic assessment and follow-up, are integral components of every
new important studies are published in the near future, these patient encounter.17 Initial triage of patients with musculoske-
will be incorporated in subsequent revisions of the guidelines letal disorders is a constant recommendation of various clinical
and recommendations may change accordingly. guidelines.18 Imaging studies are used most practically as
confirmation studies once a working diagnosis is determined.
What These Guidelines Do and What They Do Not Do The objective is to determine the presence of clinical indicators
These guidelines are intended to address issues faced by of serious pathologies (red flags) requiring diagnostic imaging,
first-contact professionals only. These guidelines do not specialist referral, or urgent surgical intervention. When a
address all possible conditions associated with musculoske- practitioner recommends that a radiograph or other diagnostic
letal disorders, only those that account for most initial visits imaging study be performed, and the patient refuses, the patient
to a practitioner. should be advised of the associated risks and implications and
Like other diagnostic tests, imaging studies should only be this should be recorded in the patient's records.
considered if (a) they yield clinically important information
beyond that obtained from the history and physical Duration of Disorders
examination, (b) this information can potentially alter patient In clinical practice, musculoskeletal disorders are gen-
management, and (c) this altered management has a reason- erally divided into categories according to the duration of the
able probability to improve patient outcomes.9-11 patient complaint on initial presentation. These diagnostic
Investigators and collaborators in the development of imaging guidelines therefore consider the following cate-
these imaging guidelines believe that liability insurance com- gories of clinical presentations: acute extremity disorder
panies, third-party payers, and courts of law should not rely (b4 weeks of duration), subacute extremity disorder (4-
solely on descriptions of patient presentations, proposed 12 weeks of duration), and persistent/chronic extremity
recommendations, and/or corresponding comments found disorder (N12 weeks of duration).
throughout the documents because patient presentations are
unique and the application of any guideline always requires Are there Potential Risks Associated with Conventional Radiographs?
clinical judgment and thus needs to be considered in the proper Although somewhat controversial,19-22 it is important to
context. In addition, laws and regulations may vary between remember that health hazards of all forms of radiation are
geographical regions and should be considered when applying cumulative.22-29 The Biological Effects of Ionizing Radiation
the proposed indications for any imaging study. (BEIR VII) 2005 report released by the National Academy of
Sciences adds further support to the linear-no-threshold
What is Evidence-Based Health Care? model of cancer risk from ionizing radiation exposure.30 In
Evidence based is about tools, not about rules. 12 summary, this report concludes that ionizing radiation is
Evidence-based health care is an approach in which dangerous even at low doses and that there are no safe limits.
clinicians and health care professionals use the current best Given the potential risks associated with conventional radio-
evidence in making decisions about the care of patients. It graphy, only appropriate clinical indications can justify its use.
Journal of Manipulative and Physiological Therapeutics Bussires et al 687
Volume 30, Number 9 Diagnostic Imaging Lower Extremity Disorders
General indications for If radiographs are indicated [B] Critical exclusionary diagnoses include:
radiographs include43,44:
Failed conservative treatment AP pelvis and AP frog leg views Osteonecrosis6
Complex history Septic arthritis
History of noninvestigated trauma Acute fractures and avulsion fractures
Significant unexplained hip pain with Malignant tumors
no previous films Also consider femoroacetabular impingement
Loss of mobility in undiagnosed condition syndrome in patients aged 2030 y (see
Acute or subacute onset of intermittent congenital/developmental abnormalities)45,46
locking Special investigations [C] MRI is the procedure of choice to exclude
Palpable enlarging mass osteonecrosis, marrow and joint disease
Consult specific clinical diagnoses and related including infection43,47
patient presentations for additional help in
decision making. Presence of one red flag
alone may not necessarily indicate the need
for radiography
Table 1 (continued)
Patient presentation Recommendations Comments
3. Nontraumatic trochanteric and iliopsoas Radiographs not initially indicated [D]
bursitis
Clinical features:
Localized tenderness and pain Special investigations [D] MRI useful in chronic or recurrent bursitis and
Moderate perceived weakness on resistive is most accurate for iliopsoas bursitis.63
testing and length-tension evaluation US is a cost-effective, easy-to-perform, and
(whereas true weakness may suggest abnor- fast alternative. However, it fails to
mality such as avulsion of underlying demonstrate iliopsoas bursitis in about 40%
muscle)62 of cases.64
4. Osteoporotic femoral neck fractures Radiographs indicated [C] Urgent orthopedic referral necessary:
Clinical features: AP spot and AP pelvis view Estimated elevated risk of osteoporotic hip frac-
Patients typically N65 YOA tures in females aged N50 y is 17.5% in Canada.67
Often before or after a fall Hip fracture is the most costly result of osteo-
Unable to walk porosis as it always requires hospitalization, is
May exhibit shortening and external rotation fatal in 20% of cases, and permanently disables a
of the affected limb and localized hip pain65 further 50%. Only 30% recover fully; 1.7 million
hip fractures occurred worldwide in 1990.68
Table 1 (continued)
Patient presentation Recommendations Comments
(b) Labral tear and femoroacetabular (b) Labral tear:
impingement Radiographic findings:
Clinical features: Typically normal in labral tears
Knife sharp groin pain Special investigations [D] Unenhanced MRI for hip articular cartilage
Painful giving way syndrome and labrum defects80
Locking MRI arthrography has high accuracy (90%)
Painful clunk or snapping hip and diagnostic arthroscopy with labral
Painful apprehension tests (forced resection79,81,82
hyperextension-external rotation in
slight abduction) Labral tear MRI findings:
Painful impingement test (forced flexion Focal chondral defects
adduction). Synovitis
Unossified intra-articular bodies
Concomitant pathologic findings, such as
intra-and extra-articular ganglia or edema of
the subchondral bone, may lead to early OA.
(It is unclear if labral tear can lead to DJD)83
MR arthrography: provide for accurate diagnosis
2. Osteoarthritis (degenerative joint disease) Radiographs indicated [B] Patients N40 YOAwith a new episode of hip pain
Clinical features: present with evidence of DJD in 44% of cases44
40 YOA AP spot and AP frog leg views
Hip pain only with possible protective limp Independent predictive factors for progression
Activity-induced symptoms that improve with of DJD of the hip: age, female sex, presence of
rest hip pain, joint space width at baseline = .5 mm,
Stiffness: in the morning or with periods of and a Kellgren and Lawrence score of 2 at
inactivity baseline (LOE III).87
May be bilateral
Significant decrease in pain with weight loss Monitoring: staging also useful for surgical
and exercise in patient N60 YOA84,85 consideration and rapid onset DJD.53,88,89
Precise reproducible radiograph required.90
Test for ROM:
Restricted and painful internal rotation: 3 planes
ROM limitations less sensitive but more
specific.86
3. Inflammatory arthritis (seronegative and Radiographs indicated [D] Rheumatology referral recommended if
seropositive) persistent inflammatory joint disease (N6
8 wk) even with analgesics and NSAID.91
Unrelenting morning stiffness N30 min, pain at AP spot and AP frog leg views
rest, pain or stiffness better with light activity, AP pelvis may also be warranted as initial study to
Radiographic changes in suspected RA:
polyarticular involvement, warmth, effusion, assess both hips
symmetrical distribution; joint effusion,
diffuse tenderness, decreased ROM; fever/
fusiform soft tissue swelling, diffuse joint space
chills or other systemic symptoms, responsive
narrowing, regional osteoporosis, marginal/
to NSAID/steroid, flexion and adduction
central erosions, subchondral bone cysts, and
contracture in long-standing arthritis
absence of osteophytes.93 Laboratory tests
RA diagnostic criteria (4 of 7 required)91,92:
necessary to exclude RA.92
Morning joint stiffness N1 h
Arthritis involving 3 joints for at least 6 wk Special investigations75,78,80 [D]
RA may involve all articular components
hand arthritis (wrist, MCP, PIP) MRI highly sensitive and often more specific than
(fibrous capsule, subchondral bone, cartilage)
Symmetric arthritis US; detection of synovial pannus, erosions,
and extra-articular structures (bursae, tendon
Rheumatoid nodules cartilage loss, small subchondral cysts, and
sheath).93
Serum Rh factor marrow edema distribution9395
Radiographic changes
Risk of osteonecrosis with high-dose US may show effusion and osseous erosions.96
corticosteroid therapy.
4. Osteonecrosis (avascular necrosis)43,47,76,97 Radiographs indicated [B] Orthopedic referral recommended
Clinical features: AP spot and AP frog leg views Abnormal radiographic appearance in
Most common in those b50 YOA Consider AP pelvis as initial examination established disease. Staging is important
M:F= 8:1; in younger patients, M:F= 4.2:1 as condition may be bilateral for osteonecrosis natural history and
Progressive groin pain that may refer to indication for treatment.
the knee Osteonecrosis results in 10% of total
Early stages: normal ROM hip arthroplasties in United States.42
(continued on next page)
690 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Lower Extremity Disorders November/December 2007
Table 1 (continued)
Patient presentation Recommendations Comments
Advanced stages: limitation of extension,
internal rotation and abduction; limping
and atrophy
Risk factors: Special investigations [B] Advanced imaging and specialist referral
Systemic corticosteroids recommended
Alcohol abuse MRI useful when radiographs are normal,
Radiation therapy especially in high-risk patients. Also NM
Chemotherapy and CT (when MRI unavailable)43,97
Metabolic disease
Some autoimmune conditions
Coagulopathies
Deep sea diving/saturation diving
Pregnancy
5. Tumors and metastatic lesions43,47,60,76 Radiographs indicated [D] Orthopedic referral essential
No specific clinical features; Spontaneous AP spot and AP frog leg views Metastatic disease, multiple myeloma, or
pathologic fracture often first sign of chondrosarcoma involving the pelvis or femur
metastasis from breast, lung, or prostate are not uncommon in older patients with hip
cancer pain.
Special investigations [D] Advanced imaging recommended:
NM, CT, MRI
6. Stress (fatigue or insufficiency) Radiographs indicated [D] Orthopedic referral recommended
fractures65,98 AP spot and AP frog leg views
Exertional anterior hip pain, especially after an Advanced imaging recommended
increase in training regimen; chronic repetitive If radiograph is inconclusive, re-radiograph after
overloads, typically in athletes or reduced 1014 d of restricted use before proceeding to Bone scan, MRI, or CT in suspected occult,
mechanical bone properties (athletic advanced imaging. osteoporotic, or stress fractures98
amenorrhea, osteoporosis, corticosteroid use)99
Special investigations [D]
Patient presentation
Adult patients with significant hip trauma Radiographs indicated [C] The degree and nature of the trauma and age of
the patient may warrant only routine images.
Delay in recognition and reduction of acute AP pelvis, AP centered of hip, right and left
dislocation, fracture, and fracture-dislocation obliques of the pelvis, and true lateral views102 Advanced imaging and specialist referral
of hip leads to preventable complications recommended:
and morbidity (LOE III).100,101
Special investigations [C] MRI for patients with significant hip pain after
injury, especially when unable to bear weight;
also to exclude occult fracture and possible
labral tear.98
NSAID, Nonsteroidal anti-inflammatory drug.
Table 2 (continued)
Patient presentation Recommendations Comments
General indications for knee radiographs When radiographs are indicated or unless Critical exclusionary diagnoses include:
include43,44,104: otherwise specified [C] Occult fractures
History of noninvestigated trauma (with signs Standing AP views for joint space integrity Septic arthritis
from the OKRsee below) Consider recumbent AP views if osseous detail Osteonecrosis
Complex history is important. Infection
Significant unexplained effusion with no Lateral view Tumors
radiographs Tunnel (intercondylar) view
Loss of mobility in undiagnosed condition
Acute/subacute onset Special investigations [C] US useful to visualize superficial soft tissue
Intermittent locking structures (tendons, collateral ligament bursae);
Unrelieved by 4 wk of conservative care US less reliable for internal structures105,106
Palpable enlarging mass May be able to differentiate between
Painful prosthesis degenerative and inflammatory causes of
Presence of one red flag alone may not painful knee103
necessarily indicate the need for radiography. MRI best for internal derangements and can
See Malanga et al104 for additional reading on often prevent unnecessary knee arthroscopy43,107
physical examination of the knee.
Specific clinical diagnoses
1. Osteoarthritis (OA)43,108110 Radiographs indicated if unrelieved by 4 wk of The prevalence of OA as the cause of knee pain
The clinical criteria for OA of the knee are: conservative care [B] among adults is 34%. OA is generally a chronic
If at least 3 of the following are present, AP, lateral, and intercondylar views if radiographs condition. However, patients sometimes present
sensitivity for OA is 0.95 and specificity is are indicated with an acute exacerbation. Radiographic
0.69. If 4 criteria are present, sensitivity is findings of OA changes are helpful when
0.84 but specificity is 0.89. Annual radiographic evaluation not indicated as diagnosis is uncertain.107,112
History: changes are often subtle and of doubtful clinical Radiologic changes not strongly related to
N50 YOA importance.111 severity of joint pain or disability;113116 trial
Morning joint stiffness b30 min of conservative treatment appropriate if no
Additional views: 45 (oblique) views if signs effusion or a small effusion is present
Physical examination: and symptoms do not correlate with standard
Crepitation views
Bony tenderness
Bony enlargement Special investigations [B] US or MRI indicated if significant effusion
No palpable warmth and/or loss of joint space117
Other characteristics include long-standing pain,
no extra-articular symptoms; aggravated
by weight bearing, climbing stairs, exercise;
nonresponsive to NSAID or corticosteroid
medication; relieved with rest; deformity or
fixed contracture, joint effusion; insidious onset.
2. Inflammatory arthritis73,91,109 Radiographs indicated [D] Rheumatology referral recommended if
(seronegative and seropositive) Consider bilateral AP standing views persistent inflammatory joint disease
Diagnosis of inflammatory arthritis of the (N68 wk) even with analgesics and NSAID91
knee is primarily based on history and Specialized care necessary if incapacitating
physical examination: instability, deformity, or pain
Unrelenting morning stiffness N30 min See hip section for radiographic changes
Pain at rest in RA93
Pain or stiffness better with light activity Laboratory tests necessary to exclude RA92
(during remission)
Polyarticular involvement, especially Special investigations: [C] US and MRI may aid in staging and as
the hands indicator of disease progression.43,75,118,119
Palpable warmth Knee aspiration if positive for effusion
Joint effusion
Decreased ROM
Fever/chills or other systemic symptoms
Responsive to NSAID or
corticosteroid medication
Flexion and adduction contracture in
long-standing arthritis
See also hip section for RA diagnostic criteria
(continued on next page)
692 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Lower Extremity Disorders November/December 2007
Table 2 (continued)
Patient presentation Recommendations Comments
3. Bursitis/tendinitis/strain/tendinosis Radiographs not routinely indicated unless [D]
Clinical features: Unrelieved by 4 wk of conservative care
Related to or aggravated by activity Suspected avulsion fracture120
Relieved or diminished symptoms at rest Underlying arthropathy
Point tenderness
Localized swelling (extra-articular) Special investigations [D] MRI120122
US: puncture of a popliteal cyst and
corticosteroid injection can be done under
US guidance123
4. Anterior knee pain Radiographs indicated if [C]
Clinical features: Unrelieved by 4 wk of conservative care
Insidious onset Suspected fracture
Aggravated with steps/incline/rising from chair Underlying arthropathy
Stiffness with rest or gliding Additional views:
Pseudolocking or giving way Tangential patellar views to evaluate for
Tender patellar facets chondromalacia, patellar tilt, or subluxation
Positive apprehension tests Stress radiographs to evaluate for patellofemoral
Crepitation instability (stress view: valgus and internal
Abnormal Q angle rotation at 45 of knee flexion)125
Clinical tests for the diagnosis of Special investigations [C] High-field MRI for chondromalacia and
chondromalacia patella have low sensitivity, synovial plicae47,122,125128
specificity, predictive values, and accuracy Contrast CT arthrography if MRI unavailable
compared with tests for arthroscopy.124
5. Internal joint derangement43,110 Radiographs indicated if unrelieved by 4 wk of Orthopedic referral or co-management
conservative care [B] recommended
Clinical features: Standard AP, lateral views if necessary after 4 wk It is important to note that radiographs often fail
History to demonstrate the cause of pain.
Acute or subacute onset
Intermittent locking and/or giving way Additional views: Possible injuries:
Crepitation, snapping, and popping Tunnel, standing lateral, standing oblique Intra-articular body
Worse with activity Meniscal tear
Improved with rest Ligamentous injury
(the accuracy of the clinical history in patients Avulsion fracture
with suspected torn ligament or meniscus is Osteochondritis dissecans
unknown) OA
Special investigations [C] MRI is gold standard for internal knee
Physical examination: derangements such as meniscal and
Joint line tenderness If diagnosis not well established from history, ligamentous injuries.43,130,131
Swelling and joint effusion examination and radiographs or in the absence Spiral CT arthrography if MRI
Loss of ROM of clinical improvement unavailable.103,132
Physical examination104,110:
Individual physical tests for meniscal lesions Meniscal tear: joint line tenderness has a
have little diagnostic value (meta- sensitivity of 0.76 (CI, 0.650.87) but low spe-
analysis.)129 However, the accuracy increased cificity, whereas McMuray test has a low
when orthopedic tests are used in sensitivity but high specificity (0.97; CI, 0.87
combination for meniscal and ligamentous 0.99). The Ege's test (weight-bearing
tear, suggesting physical examination is McMurray's test) may be superior (84%, 0.64,
usually normal in patients without damage to and 0.90 for accuracy, sensitivity, and specificity,
these structures (see comments).110 respectively)
Ligamentous tear: the best studied tests are the
Lachman maneuver (sensitivity, 0.87 [CI, 0.76
0.98]); specificity, (0.93 [CI, 0.890.96]), the
pivot test (lower sensitivity but higher speci-
ficity (0.97 [CI, 0.930.99]), and the Anterior
Drawer Test (low sensitivity but specificity of
0.87 [CI, 0.830.97]).
CI of 95%
Journal of Manipulative and Physiological Therapeutics Bussires et al 693
Volume 30, Number 9 Diagnostic Imaging Lower Extremity Disorders
Table 2 (continued)
Patient presentation Recommendations Comments
Adult with acute knee injury but negative Radiographs not routinely indicated [B] Patient should be advised to return for follow-up
findings for the OKR indicates that a if their pain has not improved in 7 d.6
fracture is very unlikely.133137
High sensitivity (N0.98) for fractures
Adult with acute knee injury and positive Radiographs indicated in the presence of one If radiographs are negative, but clinical signs
findings for the OKR133140 or more of the OKR criteria [A] are persistent, repeat films should be obtained
AP supine and lateral views 710 d after onset. Callus or deformity may
Radiographs required only in the presence of become visible in the first month.
postinjury knee pain and any one of the
following findings: Knee fractures usually accompanied by
55 YOA Additional views: ligamentous or meniscal damage6 (see internal
Isolated tenderness at the head of the fibula or Bilateral oblique, tunnel, and tangential views joint derangement)
patella
Inability to flex knee N90 Possible osseous injuries:
Inability to walk 4 weight-bearing steps both Tibial plateau fracture
immediately and at presentation Anterior tibial spine fracture
Small intra-articular bone fragments
Radiographs should also be obtained in the Segond fracture (underlying ACL tear)
presence of obvious deformity or mass. Intra-articular fractures (lipohemarthrosis sign
on horizontal beam radiograph)
The following factors exclude patients from the
OKR: Special investigations [C] Advanced imaging and orthopedic referral
b18 YOA recommended:
Pregnancy Valgus stress radiographs under general
Isolated skin injury anesthesia125
Referred with outside films MRI is the modality of choice for initial
7 d since injury investigation of knee trauma.
Multiple injuries CT, US, and angiogram may be needed for
Altered level of consciousness additional information6,132134
Paraplegic
CI, Confidence interval; OKR, Ottawa Knee Rules.
Table 3 (continued)
Patient presentation Recommendations Comments
Altered sensorium: cognitive or sensory
impairment (neurologic deficit), head
trauma, intoxicated
(b) Foot (positive OAR)43,141149 Foot radiographs indicated [B] Look for fracture-dislocation (Lisfranc) as it has
Radiograph required only if there is pain in the When feasible, weight-bearing foot AP, lateral, been estimated that 20% of Lisfranc injuries are
midfoot zone and any of these findings: medial oblique views. missed on initial radiography, in which case,
Bone tenderness of base of fifth metatarsal Comparison views (of normal foot) may sequelae can be severe.155-157 (non-weight-
Bone tenderness of navicular bone be helpful154 bearing views can be normal)
Unable to bear weight both immediately and For possible stress fracture, see chronic foot
in clinic Additional view pain-forefoot section (C3).
Tangential view of calcaneus for heel trauma cases
ddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd
Special investigations for ankle and foot [D] Advanced imaging and orthopedic referral
recommended:
MRI or CT appropriate in presence of
significant pain and disability and negative
radiographs158
Fluoroscopic stress examination under
anesthesia to assess ankle instability
NM for persisting symptoms to exclude
stress fracture
Adult with acute toe injury Radiographs indicated [GPP] Radiography of the foot not required in the
Consider obtaining foot radiographs in presence AP, oblique, and lateral views limited to the toes absence of metatarsal injury and normal
of significant metatarsal pain (see OAR-foot) physical exam
Adult with chronic ankle and tarsal pain159 Radiographs indicated [D] When an osteochondral fragment can be seen on
Radiographs routinely obtained as first option to AP ankle, lateral, medial oblique (mortise) views a radiograph, ligamentous injury is usually
exclude: (Medial oblique view helps evaluate the detectable clinically.
Arthritis talocalcaneal relationship and lateral malleolus)
Infection If radiograph appears normal with clearly
Fracture and stress fracture abnormal clinical examination: MRI and
Neoplasm diagnostic anesthetic injection may be indicated
depending on pain, severity, and disability.
Specific indications for radiographs Additional view:
include159,160: Stress radiographs may be considered, but little
Suspected osteochondral lesion/stress fracture agreement exists as to which technique.162164
Suspected tendinopathy with possible
inflammatory arthritis Special investigations [D] MRI is the gold standard for musculoskeletal
Possible ankle instability; Single-leg jump test assessment if radiography is positive or if
as clinical indicator of functional instability unrelieved by 4 wk of conservative care.158
Journal of Manipulative and Physiological Therapeutics Bussires et al 695
Volume 30, Number 9 Diagnostic Imaging Lower Extremity Disorders
Table 3 (continued)
Patient presentation Recommendations Comments
Noninvestigated chronic ankle and tarsal pain MRI needed to exclude posttraumatic
Multiple sites of degenerative joint disease as osteochondritis dissecans in ankle pain
visualized on radiographs of other regions persistingN 68 wk
Possible operative candidate Contrast-enhanced, fat-suppressed, 3D, fast-
gradient (or equivalent) MRI may be useful
For more information, see Grassi et al.161 in diagnosing synovitis and soft tissue
impingement.
Table 3 (continued)
Patient presentation Recommendations Comments
58,175,176
4. Tarsal tunnel syndrome Radiographs not routinely indicated [D]
Clinical features:
Tingling pain and burning over the sole of the Special investigations175179: [D] MRI best for differential diagnosis of the
foot after prolonged standing or walking US or MRI for nerve and other soft tissue following:
Worse at night in some visualization Interdigital neuroma
Positive Tinel sign CT for bony abnormalities Plantar fascitis
Positive nerve compression test Sensory conduction velocity and distal Tibialis posterior tenosynovitis
2-Point discrimination motor latency useful for diagnosis and Tarsal coalition
Hypoesthesia on sole of foot treatment progression
Rare weakness of toe flexion Consider local injection therapy for persistent
pain and disability in cases of failed
conservative therapy.180
Adult with chronic foot pain181,182 Radiographs indicated [C] Medial oblique helps evaluate forefoot and
Differential diagnosis: Nonweight-bearing AP, lateral, medial, lateral oblique the tarsal and Chopart joints.
Common complications of diabetes mellitus and lateral oblique views
In suspected RA, foot radiographs may show
Neuroarthropathy Additional views: erosions even when symptomatic hand(s)
Foot infection Lateral views for toes appear normal.6
Arthritis Axial and lateromedial tangential views High prevalence of midfoot and forefoot
Most of the common forms of arthritis involvement in RA (53%92%). Hindfoot
for sesamoid bones
affect the feet and can cause foot pain and ankle affected later.183,184
Vasculitis Laboratory investigations (blood and synovial
Neurologic involvement fluid) recommended:
Polyneuropathies
Cervical myelopathies Special investigations [D] NM, MRI, US, arthrography may be useful181,182
Sciatica
Mononeuritis multiplex
A. Hindfoot-heel pain43,161,182,185 Radiographs indicated only in specific Radiographs used to exclude trauma of the
Differential diagnosis: circumstances [C] calcaneus and tarsal coalition
Plantar fasciitis (common) AP, lateral, and medial oblique views of the foot
Calcaneal stress fracture
Tarsal tunnel syndrome Additional views:
Diabetes mellitus Tangential view of the calcaneus and lateral
Long-term hemodialysis calcaneus view
Achilles or plantar enthesopathy
Inflammatory arthritis Special investigations43,103: [D] MRI if unrelieved by 4 wk of conservative
Consider reactive arthritis (Reiter care or before orthopedic or pediatric referral
syndrome) with bilateral heel pain in young Achilles enthesopathy: power Doppler
patient (second decade) with heel pain and toe sonography may show neovascularization
inflammation that may be the cause of pain
Table 3 (continued)
Patient presentation Recommendations Comments
A2. Sinus tarsi syndrome Radiographs not initially indicated [D] Radiographs generally not valuable in this
Clinical features: assessment. Furthermore, radiography does not
Mechanism: inversion injury or inflammatory depict any signs of hindfoot instability unless
joint diseases stress views are performed.194
Lateral foot pain Sinus tarsi syndrome may result in OA of
Perceived foot instability subtalar joint.
Tenderness of the sinus tarsi
No agreement on pathognomonic history, Special investigations [D] MRI if unrelieved by 4 wk of conservative
clinical tests, or imaging studies that could care: may be helpful for detecting subtle
help in confirming the diagnosis or unilateral deformities195
establishing the etiology; may be related to
instability of the subtalar joint193
B. Midfoot pain (nontraumatic)161 Radiographs indicated if unrelieved by 4 wk of Midfoot erosive disease difficult to assess on
Midfoot pain usually self-limiting conservative care or in suspected inflammatory radiographs
Differential diagnosis: arthritis [D]
RA AP, medial oblique, and lateral views of the foot
Psoriatic arthritis
Reactive arthritis (Reiter disease) Additional views:
Gout Weight-bearing ankle series may be useful
Diabetic neuroarthropathy
Diabetic infection Special investigations [GPP] CT or MRI warranted in suspected or proven
If radiography is positive or if unrelieved by 4 wk disease, but negative/equivocal radiographs.
of conservative care: White blood cell tagged bone scan to
differentiate between infection and diabetic
neuroathropathy
Specific clinical diagnoses
B1. Acquired flat foot with posterior tibial Radiographs indicated if unrelieved by 4 wk of Other causes of flatfoot
tendon dysfunction/rupture196199 conservative care or in suspected inflammatory Inflammatory arthritis
Posterior tendon rupture results in: arthritis [D] Tarsometatarsal OA
Acquired flatfoot AP, medial oblique, and lateral foot radiographs Tarsal coalition
Valgus hindfoot Additional views: Neuropathic arthropathy
Forefoot abduction Weight-bearing ankle series may be useful Traumatic ligament disruption
Clinical features: Neuromuscular diseases
Medial ankle/foot pain initially
May lead to disabling weight bearing Special investigations [D] MRI better at differential diagnosis of medial
symptoms ankle/foot pain.
Talonavicular subluxation US may be useful
Difficulty or inability to perform single-limb
heel rise For review of MRI usefulness, see Yu and
Weak resisted inversion of fully flexed foot Tanner.200
B2. Navicular tuberosity pain and Radiographs indicated if unrelieved by 4 wk of
tenderness182 conservative care [C]
Potential painful normal variants such as AP, medial oblique, and lateral foot views
accessory navicular bone (4%21% of the
population) have been described.
Painful fibro-osseous junction of the accessory Special investigations [GPP] MRI to differentiate accessory navicular from
bone an avulsion fracture
NM may be useful to help identify or confirm
site of pain.
B3. Complex regional pain syndrome Radiographs indicated [D] Diffuse osteopenia seen in 70% of cases.
Synonyms: AP, lateral, and medial oblique views of the foot
Reflex sympathetic dystrophy
Sudek's atrophy Special investigations [D] Advanced imaging and orthopedic referral
Clinical features: recommended:
Pain MRI is useful in detecting numerous soft
Tenderness tissue and earlier bone and joint processes
Swelling that are not depicted or as well characterized
Diminished motor function with other imaging modalities.200
(continued on next page)
698 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Lower Extremity Disorders November/December 2007
Table 3 (continued)
Patient presentation Recommendations Comments
Vasomotor and sudomotor instability 3-Phase NM scan recommended if radiograph
Associated conditions: is not diagnostic (sensitivity, 0.100;
Fractures or other trauma specificity, 0.80; positive predictive value,
CNS and spinal disorders 54%; negative predictive value: 100%)
Peripheral nerve injury148
Specific clinical diagnoses
C. Forefoot pain Radiographs not routinely indicated unless
Common site of foot pain unresponsive to 4 wk of conservative care or
Etiologies not easily identifiable by physical if inflammatory or infectious etiology suspected
examination201 [B]
See recommendations for the following specific
clinical diagnoses: AP and lateral foot views
C1. Metatarsal bursitis
C2. Morton neuroma182 Special investigations [D] MRI useful in differential diagnosis of forefoot
C3. Stress fracture4 pain such as stress fracture, metatarsophalangeal
C4. Osteonecrosis synovitis, and intermetatarsal bursitis184,201
C5. Hallux rigidus and hallux valgus4
C6. Sesamoiditis
C3. Stress (fatigue or insufficiency) Radiographs indicated [D] If radiograph is inconclusive, re-radiograph after
fracture43,203,204 AP and lateral foot views with or without medial 6 wk of restricted use before proceeding to
High-risk patients: oblique specific to the area of complaint advanced imaging
(a) Athletes:
Running Special investigations [C] High-field MRI with fat suppression or
Dancing inversion recovery protocol. As sensitive as NM
Walking (100% sensitive)43,205
Other weight-bearing sports CT still uncertain43; some centers use US
Clinical features:
Pain and tenderness in the:
First, second and third metatarsal
Calcaneus
Medial sesamoid
Navicular
C4. Osteonecrosis of the metatarsal head Radiographs indicated: [C] Radiographic findings (metatarsal head):
(Freiberg infraction)6 AP, lateral, with or without medial oblique Increased density
Clinical features182: of the foot Flattening, collapse
Adolescent patient Cystic changes
Pain Widening of MTP joint
Journal of Manipulative and Physiological Therapeutics Bussires et al 699
Volume 30, Number 9 Diagnostic Imaging Lower Extremity Disorders
Table 3 (continued)
Patient presentation Recommendations Comments
Tenderness Special investigations [C] MRI modality of choice to evaluate
Swelling bone marrow changes in early stages
Limitation of movement at metatarsal head
Second or third head most commonly affected
C5. Hallux rigidus and hallux valgus (first Radiographs not routinely indicated unless Radiographs, if obtained, are usually for
MTP joint) unresponsive to 4 wk of conservative care [D] assessment pre- and post-bunion surgery.43
Both very common foot disorders resulting in Lateral view most useful for dorsal osteophyte on
significant morbidity. the metatarsal head and possible osseous Chronic tophaceous gout characterized by extra-
Possible cause includes DJD, hallux fracture, fragments209 and intra-articular erosions, often causing Martel's
and fibrous dysplasia.206208 hook (overhanging margin of bone erosion).165
Differential diagnosis: Additional view210:
Gout Weight-bearing series to quantify degree of valgus Degree of valgus deformity may influence
CPPD deformity management (orthotics or surgery)
Hydroxyapatite
C6. Sesamoiditis211 Radiographs not routinely indicated unless Possible complications in physically active
Painful inflammatory condition caused by unresponsive to 4 wk of conservative care: [D] young and middle age:
repetitive injury; reactive tendinitis, Avascular necrosis
synovitis, or bursitis common Additional view: Nonunion fracture
Lateromedial and tangential views for sesamoid Hypoplasia
bones Osteochondrosis
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APPENDIX A. LIST OF ABBREVIATIONS AND GLOSSARY FOR MRI: magnetic resonance imaging
LOWER EXTREMITY DISORDERS NM: nuclear medicine (bone scan)
OAR: Ottawa ankle and foot rules
ACL: anterior cruciate ligament OKR: Ottawa knee rules
AP: Anteroposterior PA: posteroanterior
AS: ankylosing spondylitis PF: plantar fasciitis
Osteonecrosis: avascular necrosis PIP: Proximal interphalangeal joint
CPPD: calcium pyrophosphate dihydrate crystal deposition ROM: range of motion
disease RA: rheumatoid arthritis
CNS: central nervous system Tendinosis: degeneration of tendons and of tendon muscle
CT: computed tomography attachments
DJD: degenerative joint disease US: ultrasound
LOE: level of evidence X-ray: plain film radiograph
MC: most common YOA: years of age
MCP joint: metacarpophalangeal joint N: greater than
MTP joint: metatarsophalangeal joint : equal or greater than
MRA: magnetic resonance arthrography : psychology/psychiatry
Table B1 (continued)
(continued)
Patient presentation Recommendations
Limping MRI or US may reveal bursitis.
Pain aggravated by active external rotation, passive internal rotation, or
palpation of sciatic notch.
3. Nontraumatic trochanteric and iliopsoas bursitis Radiographs not initially indicated [D]
Clinical features:
Localized tenderness and pain Special investigations [D]
Moderate perceived weakness on resistive testing and length-tension MRI useful in chronic or recurrent bursitis and is most accurate for
evaluation (whereas true weakness may suggest abnormality such as iliopsoas bursitis
avulsion of underlying muscle)
US is a cost-effective, easy-to-perform, and fast alternative. However, it
fails to demonstrate iliopsoas bursitis in about 40% of cases.
4. Osteoporotic hip fractures Radiographs indicated [C]
Clinical features: AP spot and AP pelvis view
Patients typically aged N65 y
Often after a fall
Unable to walk Special investigations [D]
May exhibit shortening and external rotation of the affected limb and If radiographs negative but clinically suspected, consider MRI, CT, or
localized hip pain NM.
Consider obtaining radiographs in adult patients with chronic hip pain Radiographs indicated [D]
unresponsive to 4 wk of conservative care or if one of the following AP spot and AP frog leg
conditions is suspected:
1. Congenital or developmental abnormalities Additional views: AP pelvis in suspicion of congenital abnormality,
2. OA (limited ROM) osteonecrosis, inflammatory arthritis
3. Inflammatory arthritis
4. Osteonecrosis Special investigations [D]
5. Tumors Unenhanced MRI done first (highly sensitive)
6. Stress fractures or undisplaced fractures MR arthrography
Anesthesia injection
Examination under local anesthesia
Diagnostic arthroscopy
Specific clinical diagnoses
1. Congenital/developmental abnormalities Radiographs indicated [D]
Plain film radiograph as primary investigation for chronic hip pain, knife Standing AP pelvis and recumbent AP false profile view
sharp groin pain, painful giving way, locking and painful clunk, and painful
apprehension and impingement tests includes:
(a) Acetabular dysplasia Additional views: Abduction view of the hip (to determine eligibility for
Exclude in athlete aged b30 y with chronic hip pain. joint preserving surgery)
Table B1 (continued)
(continued)
Patient presentation Recommendations
abduction)
Painful impingement test (forced flexion adduction)
2. Osteoarthritis (OA) Radiographs indicated [B]
Clinical features: AP spot and AP frog leg views
Age 40 y
Hip pain only with possible protective limp
Activity-induced symptoms
Improvement with rest
Stiffness: in the morning or with periods of inactivity
May be bilateral
Significant decrease in pain with weight loss and exercise in patient aged
N60 y
Table B1 (continued)
(continued)
Patient presentation Recommendations
AP pelvis, AP centered of hip, right and left obliques of the pelvis, and
true lateral views
Table B2 (continued)
(continued)
Patient presentation Recommendations
Related to or aggravated by activity Suspected avulsion fracture
Relieved or diminished symptoms at rest Underlying arthropathy
Point tenderness Special investigations [D]
Localized swelling (extra-articular) MRI
Puncture of a popliteal cyst and corticosteroid injection can be
done under US guidance.
4. Anterior knee pain Radiographs indicated if [C]
Clinical features: Unrelieved by 4 wk of conservative care
Insidious onset Suspected fracture
Aggravated with steps/incline/rising from chair Underlying arthropathy
Stiffness with rest or gliding
Pseudolocking or giving way Additional views:
Tender patellar facets Tangential patellar views to evaluate for chondromalacia, patellar
Positive apprehension tests tilt or subluxation
Crepitation Stress radiographs to evaluate for patellofemoral instability (stress
Abnormal Q angle view: valgus and internal rotation at 45 of knee flexion)91
Clinical tests for the diagnosis of chondromalacia patella have low sensitivity,
specificity, predictive values, and accuracy compared with tests for arthroscopy. Special investigations [C]
High-field MRI for chondromalacia and synovial plicae
Contrast CT arthrography if MRI unavailable
5. Internal joint derangement Radiographs indicated if unrelieved by 4 wk of conservative care [B]
Clinical features: Standard AP, lateral views if necessary after 4 wk
History
Acute or subacute onset Additional views: tunnel, standing lateral, standing oblique
Mechanism of injury
Intermittent locking and/or giving way Special investigations [C]
Crepitation, snapping, and popping If diagnosis not well established from Hx, examination and
Worse with activity radiographs or in the absence of clinical improvement
Improved with rest MRI is gold standard for internal knee derangements such as
(The accuracy of the clinical history in patients with suspected torn ligament or meniscal and ligamentous injuries
meniscus is unknown.) Spiral CT arthrography if MRI unavailable
Physical examination:
Joint line tenderness
Swelling and joint effusion
Loss of ROM
Meniscal tear: joint line tenderness, McMuray, and Ege's test (weight-bearing
McMurray test)
Ligamentous tear: Lachman maneuver, pivot test, and the Anterior Drawer Test
Adult with acute knee injury but negative findings for the OKR indicates that Radiographs not routinely indicated [B]
a fracture is very unlikely.
Consider radiographs only of patients excluded from the OKR: Patient should be advised to return for follow-up if their pain has not
b18 YOA improved in 7 d
Pregnancy
Isolated skin injury
Referred with outside films
7 d since injury
Multiple injuries
Altered level of consciousness
Paraplegic
Adult with acute knee injury and positive findings for the OKR
Radiographs indicated in the presence of one or more of the OKR criteria [A]
Radiographs required only in the presence of postinjury knee pain and any one of AP supine and lateral views
the following findings:
55 YOA Additional views: bilateral obliques, tunnel, and tangential views
Isolated tenderness at the head of the fibula or patella
Inability to flex knee N90 Special investigations [C]
Inability to walk 4 weight-bearing steps both immediately and at presentation Valgus stress radiographs under general anesthesia
MRI is the modality of choice for initial investigation
of knee trauma.
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Table B2 (continued)
(continued)
Patient presentation Recommendations
Radiographs should also be obtained in the presence of obvious CT, US, and angiogram may be needed for additional information.
deformity or mass.
Table B3 (continued)
(continued)
Patient presentation Recommendations
(a) Anterolateral impingement
Clinical features: Radiographs indicated [D]
Mechanism: inversion injury AP, lateral, and mortise ankle views
Pain and localized tenderness in region of anteroinferior Additional view: [D]
tibiofibular and/or anterior talofibular ligament Stress radiographs may be considered.
Positive impingement sign
(b) Anterior impingement Radiographs indicated [D]
Clinical features: AP, lateral, and mortise ankle views
Mechanism: supination or repeated dorsiflexion injury
Anterior pain
Painful and restricted dorsiflexion
(c) Anteromedial impingement Radiographs indicated [D]
Clinical features: AP, lateral, and mortise ankle views
Mechanism: inversion injury or ankle/talar fracture
Anteromedial pain and tenderness
Swelling
Pain and restriction on dorsiflexion and supination
(d) Posterior impingement Radiographs indicated [D]
Clinical features: AP, lateral, and mortise ankle views
Mechanism: impingement of os trigonum between talus and
posterior tibia
Common in ballet dancers Special investigations [D]
Pain elicited with full weight-bearing in maximum plantar MRI for os trigonum syndrome
flexion, especially when os trigonum is present. Pain with passive plantar flexion
Tenderness behind lateral malleolus
2. Peroneal tendinosis Radiographs not routinely indicated [D]
Clinical features: Unless unrelieved by 4 wk of conservative care or patient has a suspected
Lateral hindfoot pain inflammatory arthritis
Cavovalgus foot deformity
Frequently affected in RA Special investigations [D]
MRI or US if there are signs of popping or clicking with foot eversion
3. Lateral premalleolar bursitis Radiographs not routinely indicated [GPP]
Clinical features:
Adventitious bursa develops after prolonged sitting with Special investigations [GPP]
inverted and plantar flexed feet US if unrelieved by 4 wk of conservative care
4. Tarsal tunnel syndrome Radiographs not routinely indicated [D]
Clinical features:
Tingling pain and burning over the sole of the foot after Special investigations [D]
prolonged standing or walking US or MRI for nerve and other soft tissue visualization
Worse at night in some CT for bony abnormalities
Positive Tinel sign Sensory conduction velocity and distal motor latency useful for diagnosis and
Positive nerve compression test treatment progression
2-Point discrimination
Hypoesthesia on sole of foot
Rare weakness of toe flexion
Adult with chronic foot pain Radiographs generally indicated [C]
Nonweight-bearing AP, lateral, medial, and lateral oblique views
Additional views:
Lateral views for toes
Axial and lateromedial tangential views for sesamoid bones
Special investigations [D]
NM, MRI, US, arthrography may be useful
Laboratory investigations (blood and synovial fluid) recommended
A. Hindfoot-Heel pain Radiographs indicated [D]
AP, lateral, and medial oblique views of the foot
Additional views: tangential view of the calcaneus and lateral calcaneus view
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Volume 30, Number 9 Diagnostic Imaging Lower Extremity Disorders
Table B3 (continued)
(continued)
Patient presentation Recommendations
Special investigations [D]
MRI if unrelieved by 4 wk of conservative care or before referral for medical care or
to podiatrist
Achilles enthesopathy: power Doppler sonography may show neovascularization,
which may be the cause of pain.
Specific clinical diagnoses
A1. Plantar fasciitis (PF) and calcaneal enthesosphyte (spur) Radiographs not routinely indicated except in young athlete [B]
Clinical features: AP, lateral, and oblique views
PF is one of the most common soft tissue foot disorders
Hyperesthesia over the plantar fascia Special investigations [D]
Risk factors: US may be initial step for advanced imaging (readily available, highly sensitive,
Decreased ankle dorsiflexion (0) low-cost, and radiation-free).
Being on their feet most of working day Doppler/power US improves US value
Obesity (body mass index N30 kg/m )
2
US, MRI, and bone scan are more sensitive in showing inflammatory changes and
thickening of the plantar aponeurosis in PF
A2. Sinus tarsi syndrome Radiographs not initially indicated [D]
Clinical features:
Mechanism: inversion injury or inflammatory joint diseases Special investigations [D]
Lateral foot pain MRI if unrelieved by 4 wk of conservative care: may be helpful for detecting subtle
Perceived foot instability unilateral deformities
Tenderness of the sinus tarsi
B. Midfoot pain (nontraumatic) Radiographs indicated if unrelieved by 4 wk of conservative care or in suspected
inflammatory arthritis [D] AP, medial oblique, and lateral views of the foot
Midfoot pain usually self-limiting.
Differential diagnosis: Additional views: weight-bearing ankle series may be useful
RA
Psoriatic arthritis Special investigations if radiography is positive or if unrelieved by 4 wk of
Reactive arthritis (Reiter disease) conservative care [GPP]
Diabetic neuroarthropathy/Charcot joints CT or MRI warranted in suspected or proven disease, but negative/equivocal
Gout radiographs
Diabetic infection
Specific clinical diagnoses
B1. Acquired flat foot with posterior tibial tendon Radiographs indicated if unrelieved by 4 wk of conservative care or in suspected
dysfunction/rupture inflammatory arthritis [D]
Clinical features: AP, medial oblique, and lateral foot radiographs
Medial ankle/foot pain initially Additional views: weight-bearing ankle series may be useful
May lead to disabling weight bearing symptoms
Talonavicular subluxation Special investigations [D]
Difficulty or inability to perform single-limb heel rise MRI better at differential diagnosis of medial ankle/foot pain
Weak resisted inversion of fully flexed foot US may be useful
B2. Navicular tuberosity pain and tenderness148 Radiographs indicated if unrelieved by 4 wk of conservative care [C]
Potential painful normal variants such as accessory navicular AP, medial oblique, and lateral foot views
bone (4%-21% of the population) have been described.
Painful fibro-osseous junction of the accessory bone Special investigations [GPP]
MRI to differentiate accessory navicular from an avulsion fracture
NM may be useful to help identify or confirm site of pain.
B3. Complex regional pain syndrome Radiographs indicated [D]
Synonyms: AP, lateral, and medial oblique views of the foot
Reflex sympathetic dystrophy
Sudek's atrophy Special investigations [D]
MRI is useful in detecting numerous soft tissue and earlier bone and joint processes
Clinical features: that are not depicted or as well characterized with other imaging modalities
Pain 3-Phase NM scan recommended if radiograph is not diagnostic
(continued on next page)
714 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Lower Extremity Disorders November/December 2007
Table B3 (continued)
(continued)
Patient presentation Recommendations
Tenderness
Swelling
Diminished motor function
Vasomotor and sudomotor instability
C. Forefoot pain Radiographs not routinely indicated unless unresponsive to 4 wk of conservative
care or if inflammatory or infectious etiology suspected [B]
See recommendations for the following specific clinical AP and lateral foot views
diagnoses:
C1. Metatarsal bursitis Special investigations [D]
C2. Morton neuroma MRI useful in differential diagnosis of forefoot pain such as stress fracture,
C3. Stress fracture metatarsophalangeal synovitis, and intermetatarsal bursitis
C4. Avascular necrosis (osteonecrosis)
C5. Hallux rigidus and hallux valgus
C6. Sesamoiditis
C1. Metatarsal bursitis Radiographs not routinely indicated unless unresponsive to 4 wk of conservative
care, or if inflammatory or infectious etiology suspected [GPP]
AP and lateral foot views
APPENDIX C. GENERAL INDICATIONS FOR ADVANCED Grenier JM, Green NA, Wessely MA. Knee MRI. Part I:
IMAGING IN EXTREMITY DISORDERS basic overview. Clin Chiropr 2004;7:84-9
Grenier JM, Wessely MA. Knee MRI. Part II: MR
Indications MRI CT NM US imaging of common internal derangements affecting the
knee. Clin Chiropr 2004;7:131-40.
Evaluation of neoplasm detected on conventional ++ +
radiographs Wessely MA. MR imaging of the ankle and foota
Determining skeletal distribution of neoplasms or ++ review of normal imaging appearance with an illustration of
other multifocal skeletal disease common disorders. Clin Chiropr 2007;10:101-11.
Internal joint derangements ++ + +
Inflammatory arthritis + + + ++
Evaluation of soft tissue injury, tendon pathology, ++ ++
calcified bursitis APPENDIX F. ACKNOWLEDGMENTS
Osteomyelitis ++ + ++ The authors express their sincere appreciation to all Delphi
Fluid collections or infections in joints or extra- ++ ++ panelists (phase 5), external reviewers (phases 4 and 7), and
articular soft tissues; unexplained soft tissue
to the quality of literature assessors (phase 2): Drs. Jeffrey
mass
Osteonecrosis ++ + + Cooley, Jonathon Egan, Michael Morgan, Julie O'Shaugh-
Complicated fractures + ++ nessy, and Jason Napuli, whose significant contributions
Suspected stress, occult fracture + + ++ were essential in the completion of this project. The authors
Complicated disease processes or findings + + are grateful to chiropractic college presidents for recom-
unexplained by more conservative tests
mending faculty members for the Delphi panel. The authors
++, First choice; +, second choice (must be determined on a case-by- have also appreciated the feedback received by colleagues in
case basis)a,b,c
a the field during and after the worldwide consultation on the
Adapted with permission from Peterson C. Canadian Guidelines for
Imaging (2002, unpublished data). Web (phase 6). Many thanks to Dr Andre Cardin of
b
Santiago RC, Gimenez CR, McCarthy K. Imaging of osteomyelitis and Universit du Qubec Trois-Rivires for his significant
musculoskeletal soft tissue infections: current concepts. Rheum Dis Clin input in the initial draft (phase 3); Drs Michelle Wessely of
North Am 2003;29(1):89-109. the Institut Franco-Europeen de Chiropratique and Julie-
c
Cardinal E, Bureau NJ, Aubin B, Chhem RK. Role of ultrasound in
Marthe Grenier of Universit du Qubec Trois-Rivires for
musculoskeletal infections. Radiol Clin North Am. 2001;39(2):191-201.
their valuable editorial input; and to Drs Carlo Ammendolia,
DC, PhD, Joe Lemire DC, MSc, John Triano, DC, PhD, and
Jacques Duranceau, MD, for providing constructive advice.
APPENDIX D. TYPICAL EFFECTIVE IONIZED RADIATION DOSE The authors are indebted to those who assisted during all or
FOR COMMON IMAGING PROCEDURES* part of the project, including Drs Mark Laudadio, DC;
Christian Eid, DC; Julie Roy, DC; Nicholas Beaudoin; and
Class Typical effective dose Examples Mme Valrie Lambert, academic and technology support,
(mSv)
Computer System Development Division at UQTR. Finally,
0 0 Ultrasound, magnetic resonance imaging the authors thank Mrs Vicki Pennick, RN, BScN, MHSc,
I b1 Radiograph: cervical and thoracic spine,
Senior Clinical Research Project Manager, Managing Editor,
extremities, pelvis, and lungs Cochrane Back Review Group, Institute for Work and Health,
for her valuable advice and pertinent comments and
II 1-5 Lumbar spine radiograph, Nuclear suggestions as a public representative.
medicine, cervical spine CT
III 5-10 Chest and abdomen CT The authors acknowledge all Delphi panelists who have
dedicated their time to this project. The following is a list of
*Classification of the typical effective dose of ionizing radiation Delphi panelists who have agreed to be acknowledged for
from common imaging procedures. Adapted from European Commis-
sion. Radiation protection 118. Referral guidelines for imaging in
their significant contribution to the research project.
conjunction with the UK Royal College of Radiologists; Italy 2001. p 21.
Allan Adams, DC, MSEd
Texas, USA, Texas Chiropractic College (Academic,
Researcher)
APPENDIX E. ADDITIONAL READING RECOMMENDED ON
MRI Peter Aker, DC, MSc, FCCS, FCCRS
Grenier JM, Wessely MA. Hip and pelvis MRI. Part 1: Ontario, Canada (Clinician, Researcher)
A basic overview. Clin Chiropr 2006; 9:92-8.
Grenier JM, Wessely MA. Hip and pelvis MRI. Part 2: Thomas F. Bergmann, DC
Common pathological conditions of the pelvis and hip. Clin Minnesota, USA, Professor, Northwestern Health Sciences
Chiropr 2006;9:150-9. University (Academic, Clinician)
716 Bussires et al Journal of Manipulative and Physiological Therapeutics
Diagnostic Imaging Lower Extremity Disorders November/December 2007