Why & When We Use Imaging In Sports Medicine

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When and Why We Use Imaging in Sports Medicine

Welcome to another episode of the Sports Medicine Podcast, Six to Eight Weeks: Perspectives
on Sports Medicine, with Dr. Nirav Pandya, Dr. Brian Feeley, and Dr. Drew Lansdown. In
today’s episode, we tackle a topic on many patients’ minds: medical imaging. From x-rays to
MRIs, CT scans, and ultrasounds, imaging plays a vital role in diagnosing and treating
orthopedic injuries. Our discussion dives into the nuances of when and why we use these tools,
providing insight into how imaging guides decision-making in sports medicine.

Understanding Imaging Modalities
Brian Feeley: Let’s start with the basics. When we talk about imaging, we’re primarily referring
to x-rays, MRIs, CT scans, and ultrasounds. Each has its unique advantages and limitations. For
many patients, x-rays seem simple and inexpensive, while MRIs often carry the allure of high-
tech precision. CT scans are less common in musculoskeletal care, and ultrasounds remain a
niche tool. Let’s break it down: why do we use each, and when?
Drew Lansdown: X-rays are our go-to for the majority of orthopedic complaints. They provide
a clear image of bone structure and help us rule out fractures or degenerative changes like
arthritis. X-rays are quick, accessible, and an essential first step in most evaluations. They allow
us to make informed decisions about next steps, whether that’s treatment or additional imaging.
Brian: That’s a great point. And for patients who want to jump straight to an MRI, it’s worth
understanding why we start with x-rays—even in cases where soft tissue injuries are suspected.
Nirav, can you walk us through a scenario where an x-ray is critical, even though an MRI might
eventually be needed?
Nirav Pandya: Absolutely. Let’s say a 15-year-old comes in with a basketball injury. They
heard a pop, had swelling, and everyone’s thinking ACL tear. The first thing we do is an x-ray to
rule out fractures or growth plate injuries. X-rays help us identify structural abnormalities
quickly. Plus, in pediatric patients, we need to assess how much growth remains, as this impacts
treatment plans. X-rays are also often required by insurance companies before an MRI can be
approved.
Brian: That’s an important point. I recently had a young athlete who came in after what sounded
like a typical ACL tear. But when we got the x-ray, it turned out to be a distal femur fracture.
This isn’t uncommon, and it’s a perfect example of why x-rays are essential in acute injuries.

When X-Rays Aren’t Enough
Brian: X-rays are invaluable, but they don’t tell the whole story. Let’s talk about MRIs, which
are a favorite tool in sports medicine. Why is an MRI so commonly ordered after an x-ray?
Drew: MRIs give us detailed images of soft tissues, like ligaments, tendons, and cartilage. For
example, with an ACL tear, we’re not just looking for confirmation of the tear but also assessing
other structures, like the meniscus or cartilage. This additional information is critical for surgical
planning. It’s not just about identifying injuries but understanding their full extent.
Brian: And for those who ask if they should wait until swelling subsides to get an MRI, the
answer is no. Swelling doesn’t obstruct our ability to see injuries—in fact, fluid can sometimes
highlight them.
Nirav: Exactly. It’s all about collecting as much information as possible to guide treatment. For
instance, if a meniscus repair is needed alongside ACL surgery, that impacts recovery timelines
and post-op care. This level of planning wouldn’t be possible without an MRI.
Brian: And it’s not just about confirming a diagnosis. It’s also about seeing what else is going
on. For example, there may be cartilage damage or other ligament injuries that aren’t
immediately apparent on physical exam.

The Role of Imaging in Chronic Conditions
Brian: Shifting gears, let’s talk about imaging in chronic conditions like rotator cuff injuries.
Drew, why do we get x-rays for something that’s largely a soft tissue problem?
Drew: With chronic rotator cuff issues, x-rays reveal compensatory changes in the joint, like
bone spurs or alignment shifts, which influence treatment options. If the joint shows signs of
advanced arthritis, the treatment approach might shift from a rotator cuff repair to a joint
replacement. An MRI may confirm the tear, but the x-ray gives us a broader context.
Nirav: And don’t forget acute rotator cuff injuries. Sometimes, the tendon’s attachment point on
the bone can fracture. An x-ray can quickly identify this, potentially eliminating the need for an
MRI.
Brian: Another example is when we’re assessing shoulder instability. Even if we’re planning to
get an MRI to look at the labrum, an x-ray can tell us whether there’s a bony injury, like a
fracture of the glenoid or humeral head, which can significantly alter the treatment plan.
CT Scans and Their Specialized Role
Brian: CT scans aren’t as common in sports medicine, but they’re invaluable in specific
scenarios. Nirav, when do you rely on CT scans?
Nirav: CT scans are fantastic for assessing fractures in detail. For example, if an x-ray shows a
fracture near a joint, a CT scan helps us evaluate the fracture’s complexity and plan surgery.
They’re also great for three-dimensional imaging, which is crucial for certain reconstructions,
like patellar instability surgeries.
Drew: In shoulder instability, CT scans help us measure bone loss in the glenoid, which
determines whether we’ll need to restore bone during surgery. They’re also routinely used for
preoperative planning in shoulder replacements, allowing us to simulate implant placement and
anticipate challenges. The detail provided by CT scans is unmatched when we’re planning
surgeries that require precise measurements, like reconstructing a fractured joint or aligning
implants.

Ultrasound: The Underutilized Tool
Brian: Ultrasound feels like the underdog of imaging in sports medicine. Nirav, where does it fit
into your practice?
Nirav: Ultrasound is incredibly useful for evaluating tendon or muscle injuries and guiding
injections. It’s quick, radiation-free, and can be done in the office. For example, in pediatric
patients, we use it to assess hip dysplasia. While it requires skill to interpret, it’s a fantastic tool
when used correctly.
Drew: I agree. While we don’t use it as extensively, our colleagues in certain specialties rely on
it for high-fidelity imaging in the office, especially for guiding procedures like injections. For
certain conditions, it’s an efficient and cost-effective alternative to MRI.
Brian: And it’s worth noting that ultrasound can also be used for dynamic assessments—looking
at how structures move in real time—which isn’t possible with static imaging like x-rays or
MRIs.

Imaging Isn’t Just for “Looking Around”
Brian: A key takeaway for patients is that imaging isn’t just a “look-see.” Every modality we
use—whether x-ray, MRI, CT, or ultrasound—has a specific purpose in guiding diagnosis and
treatment. We’re not ordering these tests arbitrarily; they’re essential tools for understanding
your injury and planning the best path forward.
Nirav: Exactly. Imaging helps us make informed decisions, whether it’s deciding on surgery,
predicting outcomes, or guiding post-op recovery. It’s not about using the fanciest tool but about
choosing the right one for each situation.
Brian: And hopefully, this discussion helps clarify why we choose one imaging modality over
another and how each plays a role in your care. From acute injuries to chronic conditions,
imaging is central to what we do in sports medicine.

Thank you for joining us on Six to Eight Weeks. If you’re curious about medical imaging or have
other sports medicine questions, tune in wherever you get your podcasts. From Spotify to
YouTube to ham radio (for Nirav’s trips to India), we’re here to keep you informed and
entertained.