1. Diagnostic Imaging for
Rehabilitation Professionals
Dana Tew PT DPT

3. Objectives
Become familiar with various medical imaging
modalities
Demonstrate understanding of the advantages
and disadvantages of different imaging
modalities
Be able to recommend the correct modality
given a case study
Integrate diagnostic imaging information into
physical therapy practice

4. Why do physical therapist need
to understand medical imaging?
• Clinical Reasons?
How will it effect treatment?
How will it effect prognosis?
What about direct access?
• Research Implications?

5. Medical Imaging
•Radiography
• Plain Film/ X-Ray/ Roentgen Rays
• Computed Tomogaphy (CT Scan)
• DEXA
• Bone Scan
•Magnetic Resonance Image (MRI)

6. Radiography

7. Basic Concepts
 What is an X-Ray?
 Electromagnetic
Radiation - short
wavelength

8. Professor Roentgen
 Discovered accidentally
in 1895
 Experimenting with a
machine that, unknown
to him, was producing x-
rays
 Saw the bones of his
hand in the shadow cast
on a piece of cardboard
in his lab

9. What Roentgen
saw Today's Image

10. Radiodensity
 When an object absorbs  X-rays not absorbed,
the X-rays - fewer screen produces
protons produced, film photons when struck,
stays light and exposes the film,
turning it dark
Radiopaque Radiolucent

11. belong?

12. The objects on the screen may
not be what they appear
 Take a piece of paper and draw a geometric shape
on it. (Square, triangle, circle etc.)
 Now take that shape and make it 3-D (square=cube)

14. What are you looking at?
 Must be familiar with I feel
exposed!
the form of a
tissue/structures, if
not, you can not
anticipate it‟s
radiological
appearance, and can
not decipher normal
from abnormal

17. A-B-C-D
 A- Alignment- is the bone in good
general alignment
 B- Bone- general bone density
 C- Cartilage- sufficient cartilage space
 D- Dee other stuff??
 Muscles, fat pads and lines, joint
capsules, miscellaneous soft-tissue
findings, bullets

18. Alignment

19. Alignment

20. Bone

21. Bone

23. What do I need to look for?
 Distal tibia and fibula
 F- fifth metatarsal base
 L- lateral process of the talus
 O- os trigonum
 A- anterior process of the calcaneus
 T- talar dome

24. Cartilage

26. Dee other stuff

27. Dee other stuff

28. The role of
imaging is to
confirm the
infection and
show extent.
Radiography will
show the
infection,
however usually
late. Radiography
has a high
specificity but low
Dang
sensitivity.
Ledermann HP, Morrison WB,
Schweitzer ME. Pedal abscesses in
patients suspected of having pedal
osteomyelitis: analysis with MR
imaging. Radiology 2002;
224(3):649-655

29. Viewing Images
 X-ray study named for the direction the beam
travels
 AP
 PA
 Lateral
 Orient film as if you were facing the patient, his/her
Left will be on your Right

30. Views
Lateral Oblique

31. Lumbar Spine, Oblique View
Superior articulating facet
Transverse process
Pedicle
Lamina
Inferior articulating facet

32. Lumbar Spine, Oblique View
“SCOTTY DOG”

33. Lumbar Spondylolysis
The defect
„lysis‟ involves
the pars
inarticularis
and can allow
the vertebra
above to
sublux
forward

34. Views
Dens
AP Open Mouth

35. Still Alive?

36. Whew…That
was close

37.  Bullet can be in
any of these
places (anterior
to posterior at
same level)
 1 - spinal cord
 2 - trachea
 3 – Superior Vena
Cava
 4 - aorta

38. Viewing Images
 A radiograph is a two dimensional
representation
 Therefore, “One View is No View”
 Two views are needed, ideally at
90 degress to one another for
proper 3-D like interpretation

39. How „bout some evidence
 Physical therapists in the military have been credentialed
to order various radiographic procedures, including plain
film radiographs, bone scans, and magnetic resonance
images (MRI), for over 30 years
 PT‟s shown to be more cost effective than ortho
surgeons in management of MSK disorders (with
no difference in outcomes)
o Daker-White G et al., J Epidemiol Comm. Health, 1999
 When given the opportunity, PT‟s order imaging
up to 50% less, with no difference in outcomes
o Greathose DG et al., JOSPT, 1994
o James JJ et al., Phys Ther, 1981
o James JJ et al., Phys Ther, 1975
 Diagnositic accuracy – No difference found
between PT‟s and Ortho‟s
o Moore JH et al., JOSPT, 2005

40. Outcome of the modified Ottawa Ankle Rules for
identifying the need for radiographs when used by A
Physical Therapist
N = 157 Fracture No Fracture
(+) OAR 6 (a) 90 (b)
(-) OAR 0 (c) 61 (d)
Sensitivity= a/(a+)=0.99 Specificity= d/(b+d)=.40
PPV=a/(a+b)=.62 NPV=d/(c+d)= 1.0
Likelihood Ratio= +LR= Sens/(1-Spec)= 1.6
Likelihood Ratio= -LR= (1-Sens)/Spec= .025

42. Ankle radiographs account for
approximately 10% of all radiographs
ordered in the emergency room.
Dunlop MG, Beattie TF, White GK, Raab GM, Doull RI. Guidelines for selective radiological
assessment of inversion ankle injuries. Br Med J (Clin Res Ed) 1986; 293(6547):603-605.
Less than 25% of ankle fractures have
adequate physical examinations, and
more than 99% had radiographs.
Vargish T, Clarke WR, Young RA, Jensen A. The ankle injury--indications for the selective
use of X-rays. Injury 1983; 14(6):507-512

43. Case Study Smith & Cleland
PTJ 2004
 9 year old female patient carried by her father to
PT clinic direct access.
 Heard pop in anterior knee while attempting a
backward flip the previous night.
 Unable to fully weight bear since injury.
 Physical Exam: isolated tenderness of the patella
and unable to fully weight bear on the effected
side. Unable to flex knee.
 What is your recommendation? What clinical
exam/ imaging modality do you want to order?
What do you think is problem? Why?

44. Ottawa Knee Rules
 Are 55 years of age or older; No
 Have palpable tenderness over the head of
the fibula; No
 Have isolated patellar tenderness; Yes
 Cannot flex the knee to 90°; Yes
 Cannot bear weight immediately following the
injury; Yes
 Cannot walk in ED Yes
Pooled Sensitivity = 100%

46. Case Study Smith & Cleland
PTJ 2004 Cont.
Radiograph
revealed
horizontal
fracture of the
lower patalla

47. To sum it up
 It is however,
relatively much more
important for a
physical therapist to
recognized the
indications for
diagnostic imaging, to
select the most
appropriate imaging
study, and to image
the appropriate
area(s) than it is to
interpret the image
o Deyle GD JOSPT, 2005

48. Computed Tomography (CT)
•X-Ray beam moves 360 around the patient
•Consecutive x-ray “slices” around the patient
•Computer can recreate 3D image of the body
•Best for evaluating bone and soft tissue
tumors, fractures, intra-articular abnormalities,
and bone mineral analysis

49. Computed Tomography (CT)

50. RV
LUNG
RA LV
LA
AORTA
SPINAL VERTEBRAL
CANAL BODY
RIB TRANSVERSE
PROCESS

57. Magnetic Resonance Imaging
(MRI)
What is a MRI?
The use of a High Power Magnet (.3 -
2.0 Teslas) To align hydrogen atoms in
the body to which a radio wave
frequency is applied to produce an
image
Higher Tesla level= increased resolution
No standardization among imaging centers

59. Indications for MRI
 Diagnosing multiple sclerosis (MS)
 Diagnosing tumors of the pituitary gland and brain
 Diagnosing infections in the brain, spine or joints
 Visualizing torn ligaments in the wrist, knee and
ankle
 Visualizing shoulder injuries
 Diagnosing tendonitis
 Evaluating masses in the soft tissues of the body
 Evaluating bone tumors, cysts and bulging or
herniated discs in the spine
 Diagnosing strokes in their earliest stages

60. T1 Vs T2
 T1  T2
 Tissue with high  Tissue with high
water content will water content will
apear dark (grey) appear white/
 Fat, edema, brighter
infection  Tissue with low
 Tissue with low water content will
water content will appear darker (grey)
appear white/  World War II
brighter  Water is white on
 Bone, lungs T2

61. T1 vs. T2
 T1 image of knee  T2 image of knee
Quad Tendon
Semimembranosus
Popliteal vein
Gastrocnemius Semitendonosus
Semimembranosus
ACL

62. Knee - MRI Sagittal
ANTERIOR POSTERIOR
CRUCIATE CRUCIATE
LIGAMENT LIGAMENT

63. PATHOLOGY
ACL Tear

64. Meniscus
Bow Tie Sign

65. Knee
Meniscus

66. Knee - MRI Sagittal
TORN POSTERIOR MEDIAL MENISCUS

67. Meniscus
Torn Meniscus- Double PCL Sign

68. Your MRI is showing
Clavicle
supraspinatus
Glenoid labrum D
S
e
c
l
a
humerus t
p
o
u
i
l
d
a
Long Head
of Triceps

69. Shoulder - MRI – Axial Plane

70. Shoulder - MRI – Axial Plane
D
D
SupS
IS

71. Shoulder - MRI – Coronal Plane
Rotator Cuff
SS Tendon
Supraspinatus
Glenoid
Fluid in
Joint

72. Shoulder
Supraspinatus Tear Subdeltoid Bursa

73. Lumbar Spine - MRI
Coronal T1 Sagittal T1 Sagittal T2

74. Lumbar Spine – MRI Axial
Axial T1 Axial T1
body disc
Axial T2 Axial T2
body disc

75. Body
Psoas
Spinal Canal

76. Lumbar Spine – MRI Sagittal T2
Herniated
disc

77. Things that make you go Hmm
 20-year-old male collegiate athlete who was
referred to physical therapy for left knee pain
 Subjective: patient reports insidious onset of
knee pain 1 yr. prior, but pain was exacerbated 3
weeks ago when he was tackled while playing
football

78. Things that make you go Hmm
 Physical Exam:
 ataxic gait with a widened, base of support
 single-limb balance > 1 second bilateral
 MMT non-specific weakness
 Reflexes present
 Clonus present on L (4 beats)
 Extension reflex with Babinski

79. Recommendations?
 What is your recommendation? What
clinical exam/ imaging modality do
you want to order? What do you think
is problem?

80. Walk JOSPT 2008
 Insert case study by
Matt Walk

81. Walk JOSPT 2008

83. DEXA SCAN
Looks at bone mineral densities
The “image” however, is secondary the important
information gathered is the bone mineral density

86. Skeletal Scintigraphy
(Bone Scan)
 Indication:
Cancer,
stress or
hidden
fractures

87. Did you see that?
 Ankle Radiograph- 20 views
 Tibia Radiograph- 6 views
 Knee Radiograph- 2 views
 Chest Radiograph- 4 views
 Hand Radiogpraph- 2 views
 Finger Radiograph- 2 views
 CT chest
 Ultrasound
 Doppler
 Abdominal aortogram
 Angiogram
 Fluroscopy

89. Good Websites
•http://www.freitasrad.net/index.html
•http://www.gla.med.va.gov/mriatlas/index.html
•http://www.mypacs.net
•http://www.info-radiologie.ch/index-english.php
•http://medinfo.ufl.edu/year1/rad6190/
•http://www.physio-
pedia.com/index.ph?title=Lectures_and_Presentations
•http://www.mskcases.com/
•TWU- anatomy tv

90. INTEGRATION
 A 54-year-old male safety consultant
 Mechanism of injury: The patient sustained
a knee injury at the age of 17 and has
periodically experienced varying levels of
pain for 37 years.
 Subjective: He began to experience
intermittent medial left knee pain about 4
months prior to seeking treatment. The pain
worsened when he climbed up or down
stairs and by twisting when weight bearing.
Knee occasionally gives out.

91. Case #1

92. Case #1

93. INTEGRATION
 A 54 y.o. female school teacher
 Recently experienced sever headache and
difficulty speaking
 Exam- presents with aphasia , dysarthria
and coughs when eating. She has
decreased strength and coordination in her
left arm.
 1st imaging option, 2nd option

94. Case #2

95. Case #2

96. INTEGRATION
 3.
 30 y.o. male who works as a construction worker
with acute back pain when he lifted a jack hammer.
Patient reports numbness and tingling present
down the back of his left leg and into his left foot
 Exam reveals weakness of dorsiflexion and great
toe extension, (+) SLR and (+) slump, (+) cough/
sneeze
 1st imaging option, 2nd option
Explain what might be the problem and why you
chose the modality

97. Case #3

98. Case #3

99. INTEGRATION
 Case 4.
 17 y/o female student who plays club volleyball with
complaints of weakness of plantar flexion and plantar
foot pain with prolonged gait. Patient reports she feels
a little weak when jumping and also walking
 Exam reveals:
 No lumbar pain
 Weakness of S1 myotome testing
 No lateral shift
 Pain free in supine; even with exercise
 No pain with cough or sneeze
• Antalgic gait due to weakness
 BMI below normal, overall excellent health

100. Case 4