First Contact Physio: Musculoskeletal Radiology Primer

Synopsis
MSK physiotherapists are taking on a new role as primary consulting practitioners across the land. This is both exciting and daunting at the same time and there is currently a gap in rapid education to equip physios for this role.

This lecture is a primer with case discussions on musculoskeletal radiology for the FCP including how radiology works and how to write a great referral.

About the author

Daniel is an MSK Radiologist specialising in diagnostic and interventional radiology for orthopaedic, sports injury and rheumatological conditions. He trained at Imperial College London and undertook a senior fellowship in MSK/Sports Imaging in Perth, Western Australia before returning to take a consultant post in Harrogate, Yorkshire.

Daniel plays an active role in education as a BSSR Executive board member, an educator in ultrasound guided injections and the founder of the Radiology Masters online learning platform.

He is also regional clinical lead of the Yorkshire Imaging Collaborative and was Director of Imaging for NHS Nightingale. Artificial Intelligence and Radiology Informatics form a major interest as a Royal College of Radiologists Informatics Committee Officer.

Transcript

1. Dr Daniel Fascia MSK Radiology Primer for FCPs
2. About the presenter Radiology SpR (Imperial College, London) Senior Fellowship (Perth, WA) Consultant Musculoskeletal Radiologist Regional Clinical Lead 
 Yorkshire Imaging Collaborative
3. Special Interests MSK diagnostics Novel image guided intervention Spinal intervention Health tech and informatics Medical Education (Radiology Masters)
4. Today’s schedule - Part 1 What is an MSK Radiologist and what do they do? How we interoperate with other clinical staff The Imaging Lifecycle: from thought to report Q&A Break
5. Today’s schedule - Part 1 Making referrals: Tips and Pitfalls Case based interactive examples Break
6. Today’s schedule - Final Interventional MSK Radiology Roundup: Ask the MSK Radiologist
7. What is an MSK Radiologist?
8. A general radiologist who has sub-specialised in musculoskeletal 
 radiology
9. Training Timeline Medical School 
 5-6yrs MBChB / MBBS
10. Training Timeline Medical School 
 5-6yrs Junior Doctor Roles 
 2-3yrs MBChB / MBBS MRCS? / MRCP? Dr
11. Training Timeline Medical School 
 5-6yrs Junior Doctor Roles 
 2-3yrs Radiology Specialist Training 
 3-4yrs MBChB / MBBS MRCS? / MRCP? FRCS Dr Specialist Trainee or Registrar
12. Training Timeline Medical School 
 5-6yrs Junior Doctor Roles 
 2-3yrs Radiology Specialist Training 
 3-4yrs MSK sub-specialisation 
 1-2yrs MBChB / MBBS MRCS? / MRCP? FRCS Diploma in MSK Radiology? Dr Specialist Trainee or Registrar Fellow
13. Training Timeline Medical School 
 5-6yrs Junior Doctor Roles 
 2-3yrs Radiology Specialist Training 
 3-4yrs MSK sub-specialisation 
 1-2yrs MBChB / MBBS MRCS? / MRCP? FRCS Diploma in MSK Radiology? Dr Consultant Specialist Trainee or Registrar Fellow 14yrs
14. 🇬🇧
15. 🌍 🇬🇧
16. What does our day look like
17. Interpreting and reporting MRI Interpreting and reporting Plain Film X-rays Diagnostic 
 MSK Ultrasound 
 Clinics Interpretation and reporting of Major Trauma and skeletal CT Supervision and interpretation of Nuclear Medicine scans
18. Interpreting and reporting MRI Vetting and Protocolling In person case review Interpreting and reporting Plain Film X-rays Diagnostic 
 MSK Ultrasound 
 Clinics Service Development Interpretation and reporting of Major Trauma and skeletal CT Authoring policy and guidance Supervision and interpretation of Nuclear Medicine scans
19. Interpreting and reporting MRI Vetting and Protocolling In person case review Advising on best imaging strategy Interpreting and reporting Plain Film X-rays Multidisciplinary Team Meetings Diagnostic 
 MSK Ultrasound 
 Clinics Service Development Interpretation and reporting of Major Trauma and skeletal CT Authoring policy and guidance Supervision and interpretation of Nuclear Medicine scans
20. Interpreting and reporting MRI Vetting and Protocolling In person case review Advising on best imaging strategy Interpreting and reporting Plain Film X-rays Multidisciplinary Team Meetings Diagnostic 
 MSK Ultrasound 
 Clinics Service Development Supervision of Trainee Radiologists on MSK attachment CPD Interpretation and reporting of Major Trauma and skeletal CT Authoring policy and guidance Education of Fellows Supervision and interpretation of Nuclear Medicine scans
21. Interpreting and reporting MRI Vetting and Protocolling In person case review Advising on best imaging strategy Interpreting and reporting Plain Film X-rays Multidisciplinary Team Meetings Diagnostic 
 MSK Ultrasound 
 Clinics Service Development Supervision of Trainee Radiologists on MSK attachment CPD Interpretation and reporting of Major Trauma and skeletal CT Research & Development Authoring papers Authoring policy and guidance Education of Fellows Supervision and interpretation of Nuclear Medicine scans
22. Interpreting and reporting MRI Vetting and Protocolling In person case review Advising on best imaging strategy Interpreting and reporting Plain Film X-rays Multidisciplinary Team Meetings Diagnostic 
 MSK Ultrasound 
 Clinics Service Development Supervision of Trainee Radiologists on MSK attachment On call work CPD Interpretation and reporting of Major Trauma and skeletal CT Research & Development Authoring papers Authoring policy and guidance Education of Fellows Supervision and interpretation of Nuclear Medicine scans Handling complaints etc
23. Interpreting and reporting MRI Vetting and Protocolling In person case review Advising on best imaging strategy Interpreting and reporting Plain Film X-rays Multidisciplinary Team Meetings Diagnostic 
 MSK Ultrasound 
 Clinics Service Development Interventional 
 MSK Injections, biopsies, advanced procedures Supervision of Trainee Radiologists on MSK attachment On call work CPD Interpretation and reporting of Major Trauma and skeletal CT Research & Development Authoring papers Authoring policy and guidance Education of Fellows Supervision and interpretation of Nuclear Medicine scans Handling complaints etc
24. How we work with other teams
25. Common clinical team links Orthopaedic Surgeons Rheumatologists Emergency Department Sports and Exercise Medicine Physiotherapists Neurosurgery, spine, oncology, physicians, other AHPs
26. Underwriters of medicine Advice on diagnostic plan Interpretation of results Part of treatment plan How we help other medical teams
27. Interventional Getting tissue (biopsy) Removing bad (drainage) Injecting good (therapies) Advanced IR procedures How we help other medical teams
28. Practical Examples
29. 13yo active
 Night pain in shin
30. 13yo active
 Night pain in shin
31. 13yo active
 Night pain in shin One view is one view too few
32. 13yo active
 Night pain in shin
33. 13yo active
 Night pain in shin Imaging features
 Age
 History of complaint
34. 13yo active
 Night pain in shin Imaging features
 Age
 History of complaint CT con fi rms
 Helps plan Rx
35. 13yo active
 Night pain in shin Imaging features
 Age
 History of complaint CT con fi rms
 Helps plan Rx RF Ablation by Interventional Radiologist Somma F, Stoia V, D’Angelo R, Fiore F (2021) Imaging-guided radiofrequency ablation of osteoid osteoma in typical and atypical sites: Long term follow up. 
 PLOS ONE 16(3): e0248589. https://doi.org/10.1371/journal.pone.0248589
36. Practical Examples
37. General Radiologist reporting body CT: That vertebra looks!?
38. General Radiologist reporting body CT: That vertebra looks!?
39. General Radiologist reporting body CT: That vertebra looks!? MSK Radiologist:
 It’s just a benign haemangioma
40. Practical Examples
41. Child with painful groin/buttock X-ray regarded as normal
42. Child with painful groin/buttock X-ray regarded as normal MSK Radiologist
43. Child with painful groin/buttock X-ray regarded as normal MSK Radiologist
 Arranges MRI Scan
44. Child with painful groin/ buttock X-ray regarded as normal MSK Radiologist
 Arranges MRI Scan Still confusion…
 Is it infection? what is it?
45. Child with painful groin/buttock X-ray regarded as normal MSK Radiologist
 Arranges MRI Scan Still confusion…
 Is it infection? what is it?
 
 Van Neck Odelberg Disease
 RARE: ischiopubic sychondritis
46. Summary so far
47. How MSK Radiologist may help you Advise on diagnostic strategy Correlate fi ndings with extensive medical knowledge Recognise rare diseases and variants of common Actuary of medicine: probability + evidence Inform treatment approach Deliver intervention
48. But physio… very practical…
49. Hands on clinical art
50. How MSK Radiologist helps physiotherapy Diagnose. 
 What are you treating? How sure are you? Reversibility. 
 Can I actually physio this better or is it trashed? Risk assess. 
 What is the condition of… before manual/exercise therapy Why am I getting nowhere? 
 Tried physio… not working. Why? What is the next step?
51. Becoming a front line medical professional
52. Managing an MSK condition in primary care Take history. 
 80% of the game Clinical Examination 
 Physios are the experts of MSK examination Differential Diagnosis 
 A probability based list of most likely aetiologies Diagnostic tests 
 Imaging, bloods etc… request, receive, interpret Management Plan
53. The Medical Imaging Lifecycle
54. Thought >>> Test >>> Result
58. X-ray Lt Hip
59. X-ray Lt Hip
60. X-ray Lt Hip
61. X-ray Lt Hip Vetted
62. X-ray Lt Hip Vetted Acquired
63. X-ray Lt Hip Vetted Acquired PACS
 Storage
64. X-ray Lt Hip Vetted Acquired PACS
 Storage Reporting
65. X-ray Lt Hip Vetted Acquired PACS
 Storage Reporting Report Delivery
66. X-ray Lt Hip Vetted Acquired PACS
 Storage Reporting Report Delivery Received
 Acknowledged
 Acted on
67. Q&A Session 1
68. TAKE A BREAK
69. What makes a good radiology referral?
70. Writing good requests Short and factual No distraction information Only relevant other Hx Mentions prior imaging / tests Asks clear question Does not try to guess best imaging
71. Writing good requests Short and factual No distraction information Only relevant other Hx Mentions prior imaging / tests Asks clear question Does not try to guess best imaging
72. Tips Sort out your IT Passwords and permissions to request electronically Make sure you can receive and act on results Understand your responsibility in using specialist imaging
73. Requesting Rules Build a relationship with your local MSK radiologists Write great requests Ask for advice and discuss cases Don’t try to guess the best imaging and “order” Give feedback and… Receive feedback
74. Q&A on referrals / requesting
75. Case Based Discussions
76. Hip Case 1 Shoulder Hip Spine
77. Shoulder Painful Arc Stiff / Restricted Trauma AC joint
78. Shoulder Painful Arc Stiff / Restricted Trauma AC joint Trauma X-ray 
 ?fracture USS 
 ?RC tear
79. Shoulder Painful Arc Stiff / Restricted Trauma AC joint Trauma X-ray 
 ?fracture USS 
 ?RC tear No X-ray >65 
 ?OA USS (inj) failed PTx
80. Shoulder Painful Arc Stiff / Restricted Trauma AC joint Frozen X-ray 
 ?normal HydroDist
81. Shoulder Painful Arc Stiff / Restricted Trauma AC joint Frozen X-ray 
 ?normal HydroDist 65 <> X-ray 
 ?OA
82. Shoulder Painful Arc Stiff / Restricted Trauma AC joint Frozen X-ray 
 ?normal HydroDist 65 <> X-ray 
 ?normal
83. Shoulder Painful Arc Stiff / Restricted Trauma AC joint X-ray 
 ?fracture, Bankart, HillSachs
84. Shoulder Painful Arc Stiff / Restricted Trauma AC joint X-ray 
 ?fracture, Bankart, HillSachs Instability? RC Tear?
85. Shoulder Painful Arc Stiff / Restricted Trauma AC joint X-ray 
 ?fracture, Bankart, HillSachs Instability? RC Tear? PTx fail 
 Shoulder Specialist MR Arthro
86. Shoulder Painful Arc Stiff / Restricted Trauma AC joint X-ray 
 ?fracture, Bankart, HillSachs Instability? RC Tear? USS PTx fail 
 Shoulder Specialist MR Arthro
87. Shoulder Painful Arc Stiff / Restricted Trauma AC joint X-ray 
 ?fracture, Bankart, HillSachs Instability? RC Tear? USS PTx fail 
 Shoulder Specialist MR Arthro Capsulitis 
 Post traumatic
88. Shoulder Painful Arc Stiff / Restricted Trauma AC joint X-ray 
 ?fracture, Bankart, HillSachs Instability? RC Tear? USS PTx fail 
 Shoulder Specialist MR Arthro Capsulitis 
 Post traumatic HydroDist
89. Shoulder Painful Arc Stiff / Restricted Trauma AC joint Trauma Degenerative
90. Shoulder Painful Arc Stiff / Restricted Trauma AC joint Trauma Degenerative X-Ray 
 Stress stability views
91. Shoulder Painful Arc Stiff / Restricted Trauma AC joint Trauma Degenerative X-Ray 
 Stress stability views X-Ray 
 ?OA
92. Shoulder Painful Arc Stiff / Restricted Trauma AC joint Trauma Degenerative X-Ray 
 Stress stability views X-Ray 
 ?OA Sternoclavicular Do not X-ray
93. Shoulder AC joint Sternoclavicular Is the patient Diabetic? 
 En garde… 
 Both of these joints suspectible to osteomyelitis
94. 38yo joiner RHD
 Sti ff , painful shoulder
 Cannot sleep
 No trauma
 3-mo Hx Shoulder Case 1
95. 38yo joiner RHD
 Sti ff , painful shoulder
 Cannot sleep
 No trauma
 3-mo Hx X-ray Shoulder Case 1
96. 38yo joiner RHD
 Sti ff , painful shoulder
 Cannot sleep
 No trauma
 3-mo Hx X-ray normal Shoulder Case 1
97. 38yo joiner RHD
 Sti ff , painful shoulder
 Cannot sleep
 No trauma
 3-mo Hx X-ray normal Shoulder Case 1 Adhesive Capsulitis Frozen Shoulder
98. Physio and NSAIDs Getting nowhere…
 Sti ff , painful
 Can’t do exercise Referred for HydroDist Shoulder Case 1 Adhesive Capsulitis Frozen Shoulder
99. Fluoroscopic Ultrasound Guided
100. Ultrasound before USS Distended
101. Posterior transinfraspinatus USS guided HydroDist Relaxed Capsule Distended Capsule
102. Intoxicated, fall onto shoulder unrestrained ED attendance to reduce Shoulder Case 2
103. Post reduction Back in joint Bankart fracture of anteroinferior glenoid rim Shoulder Case 2
104. Post reduction Back in joint Bankart fracture of anteroinferior glenoid rim Instability repeated dislocations Shoulder Case 2
105. 3D-rendered CT scan was used for planning of stabilisation surgery Shoulder Case 2
106. Sometimes…
 Non osseous Bankart
 Labral injury
 
 MR Arthrography Shoulder Case 2
107. Shoulder Case 3 Amateur rugby “Big hit” injury Instant pain over AC joint Concern of fractured clavicle ED attendance
108. Shoulder Case 3
109. Shoulder Case 3
110. Shoulder Case 3 Rockwood Grade III ACJ injury
111. Shoulder Case 4 65 Male diabetic Very painful arc abduction 
 Sharp pain lying on shoulder 
 Disturbing sleep
112. Shoulder Case 4 45 Male diabetic Very painful arc abduction 
 Sharp pain lying on shoulder 
 Disturbing sleep USS vs X-ray?
113. Shoulder Case 4 45 Male diabetic Very painful arc abduction 
 Sharp pain lying on shoulder 
 Disturbing sleep No right answer! Severe Calci fi c Tenindopathy
114. Shoulder Case 4 Severe Calci fi c Tenindopathy
115. Shoulder Case 4 US Guided Barbotage and Lavage Procedure
116. Shoulder Case 4 US Guided Barbotage and Lavage Procedure
117. Understanding Normal
118. The common 
 things Understand
 Spectrum
 Findings Osteoarthritis
119. Enthesopathy
120. Enthesopathy
121. Hip Case 1 Metastatic bone destruction (lateral) https://www.pacsbin.com/c/WywOUjuyCH
122. Hip Case 2 Ankylosed SI joints https://www.pacsbin.com/c/bknZ3lMYbU
123. Hip Case 3
124. Hip Case 3
125. Hip Case 3 Stage II AVN right hip
126. Hip Case 3 Stage II AVN right hip Sensitivity of X-ray
127. Spine
128. Spine Case 1 Attends primary care Long Hx of back pain with prior MR showing disc hernia Worsening Symptoms Dif fi culty passing urine. 
 Change in sensation around groin. https://www.pacsbin.com/c/WkIPkiEkZD
129. Spine Case 1 Old scan comparison Acute new scan
130. Spine Case 1 Old scan comparison Acute new scan Cauda equina compression CSF space eradicated
131. Spine Case 3 Removal man 
 Lifting heavy sofa with colleague Pop sensation in back 
 Left leg numb, radiation of pain down back of leg https://www.pacsbin.com/c/ZJ6y-pHnkI
132. Spine Case 2 Disc extrusion Disc bursts 
 Annular material escapes Left S1 (+ dist) 
 compression
133. Spine Case 3 Elderly gentleman in care home 
 Longstanding back pain 
 Increased back pain and reduced mobility Fever and rigors 
 Raised CRP 
 Several hospital visits fail to show infection source https://www.pacsbin.com/c/-kVF1NHFSB
134. Spine Case 3 STIR (fat suppressed) T1 post Contrast T1
135. Spine Case 3 STIR (fat suppressed) T1 post Contrast T1
136. Spine Case 3 STIR (fat suppressed) T1 post Contrast T1
137. Spine Case 3 STIR (fat suppressed) T1 post Contrast T1
138. Spine Case 3 STIR (fat suppressed) T1 post Contrast T1 Spondylodiscitis + Osteomyelitis
139. MRI the problem solver Fantastic problem solving algorithm Design scan sequences to suit problem with radiologist 
 Provide them good information! Anatomical information Biological information 
 Inflammation, blood flow etc
140. Dr Daniel Fascia Thanks for listening danielfascia@yorkshireradiology.com @danfascia