Posted on Jan 24, 2020
While most afflictions can heal over time or with proper treatment, a misdiagnosed or mistreated injury can have life-long and sometimes debilitating consequences. Having your medical scans read by a radiology subspecialist can help prevent diagnostic errors, ensuring an accurate diagnosis and the smoothest possible road to recovery.
82% of patients who get a second opinion from a musculoskeletal (MSK) subspecialty radiologist end up with a more accurate diagnosis. - American Journal of Roentgenology.
To better understand the complexities of musculoskeletal imaging we spoke to Dr. Vaishali Lafita, a leading MSK and MRI radiologist who has treated professional athletes including members of the Chicago Bulls and Chicago Bears. In this exclusive interview, she tells us why a second opinion is so important for sports injury diagnosis and offers valuable advice for patients going through the diagnostic process.
[DocPanel] What are some of the biggest challenges in diagnosing sports injuries and how can a second opinion help overcome them?
[Dr. Lafita] Over the last decade or so, there’s been an increase in sports participation, especially among children and young adults. As a result, acute injuries happen much more frequently. But medical scans of the musculoskeletal system can be challenging to read. And even though they require the expertise of a subspecialist, either an MSK radiologist or an MSK MRI expert, many are being read by general radiologists. This increases the chance of medical errors.
For example, due to the increase in activity among the general population, we’re seeing an accelerated rate of wear and tear in patients. So the interpreting radiologist needs to be able to accurately distinguish between what is actually a critical injury versus what might just be wear and tear. This requires training and experience that general radiologists won’t have necessarily had.
Subspecialty second opinions give patients the opportunity to ensure that the best-suited expert has looked over their scans. This can have a huge impact on the accuracy of a sports injury diagnosis.
I recently provided a second opinion for a patient who had two MRIs of the same joint a year apart with no concrete diagnosis and therefore persisting symptoms due to lack of treatment. Based on the second opinion report I provided her with after interpreting her scans, she was able to get appropriate treatment for her ongoing symptoms. This is the value of a second opinion.
While there are different avenues for patients to seek a second opinion, a great thing about DocPanel is that it makes specialty care more accessible. If the clinic a patient received care from only has generalists - they can still have an expert look at their scans without having to pay a ton of money to be seen at a specialty clinic. It’s great for international patients as well, who simply don’t have access to subspecialty radiologists in the area they’re living or traveling through.
[DocPanel] What is the first step in diagnosing a sports injury?
[Dr. Lafita] When you decide to seek treatment for persisting aches and pains or an acute injury, who you see for that initial appointment will determine the next step. So it’s really important to get a good clinical exam by a trained professional.
Based on that clinical exam, your doctor (whether a family practitioner or a pediatric, sports medicine or orthopedic specialist) will come up with a working diagnosis of why you are having symptoms or what structure of a particular joint may be injured or in need of attention. After evaluating your condition, they’ll decide if any imaging tests are needed, like an x-ray or MRI.
Just as there is value in having a subspecialty radiologist provide all diagnostic interpretation of medical imaging, there is also extra added value in having a more specialized doctor perform the clinical exam. Sports medicine is complicated. Specialization allows for a more precise working diagnosis.
[DocPanel] Which types of medical scans are the best for sports injury diagnosis?
[Dr. Lafita] X-rays are a great starting point. They provide a generalized overview of a specific joint or bone and are especially useful in ruling out fractures, which helps determine the next step in management.
X-rays also play an important role in the diagnostic process by letting physicians know which imaging modality should be used next. If there is a fracture, the orthopedic surgeon may order a CT scan (CAT scan) to determine the complexity of the fracture for presurgical planning. If no abnormalities show up in an X-ray, it’s a great indication that there may be a soft tissue injury in the ligaments, muscles, labrum, menisci or bones. For patients with suspected soft tissue conditions, an MRI is the best follow-up test.
[DocPanel] MRI scans can be such a valuable diagnostic tool. But a lot goes into taking the scan and reading it. What advice do you have for patients?
[Dr. Lafita] In terms of where you go, here are some really important things to consider when you have an order for an MRI.
The strength of the MRI machine being used to take your scan:
The quality of an MRI image generally depends on the strength of the MRI scanner. The higher the strength, the better-quality image it will produce in terms of resolution and details.
It’s a radiologist’s job to look at the images, interpret what they see, and come up with a diagnosis. The more details captured on an MRI, the more information the radiologist will be able to extract from the exam. This all impacts the final diagnosis. In fact, many of my orthopedic surgeon and sports medicine colleagues request that all patients have their scans taken on MRI machines with a field strength of 1.5 Tesla or more.
The sequence (technique) being used to take your scan:
The sequence, in other words, the technique, that is used to obtain an MRI scan also affects image quality and, thus, diagnostic outcome.
While there are standard recommendations by the American College of Radiology (ACR) for specific body parts, each MRI center may employ their own choice of technique to optimize scanning. Most specialty radiologists will also have their own sequencing preferences.
Other radiologists, however, might have been trained before MRI became so widely used. Most of these radiologists are self-taught MRI readers. Similarly, there are some who trained so long ago that they may not be familiar or comfortable with more modern/updated imaging parameters or sequences. This can be an issue at times, impacting the accuracy and capabilities of the scan.
For example - in my previous practice, the radiologist who was also my boss kept the same MRI protocols that were used in the early ‘90s. Technical advances are being implemented to improve characterization and therefore improve accuracy - when you use antiquated technique, it can limit evaluation or characterization to detect abnormalities.
The speed at which the scan is taken:
Whether for patient preference or to optimize an imaging center’s workflow, some MRIs are executed at a higher speed. While some of these faster techniques may be similar to what the ACR recommends, if it’s too far off it can impact the accuracy of the study.
If the speed is too high, important sequences can be missed which could hide some pathology or limit further characterization of pathology seen on the included sequences.
Another helpful thing about getting an expert second opinion is that a specialist will be able to tell you if the study quality is too poor and should be retaken.
[DocPanel] What are some of the most commonly misdiagnosed sports injuries?
[Dr. Lafita] When it comes to sports injury diagnosis - missed diagnoses and over-diagnoses are both an issue.
Some commonly missed diagnoses on MRI are ACL/PCL tears, far peripheral meniscal tears, muscle injuries, and stress injuries. The severity of a ligament and tendon injury is also commonly misdiagnosed.
Rotator cuff tears, meniscal tears, labral tears, and ligament tears are some of the most overly diagnosed conditions.
Missed diagnosis errors can result in ongoing symptoms for the patient that could have been treated or averted. Unnecessary additional testing may also end up being ordered, resulting in unncesseary medical bills. On the flip slide, overdiagnosis can lead to unnecessary and potentially harmful treatment, like arthroscopy and/or surgery.
MRI studies with optimal sequences are able to demonstrate the pathology of bones, joints, ligaments, and muscles. For most misdiagnoses, there are usually findings present on the scans that a second opinion reader can catch to correct the sports injury diagnosis.
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[DocPanel] What is the most important step in a sports injury diagnosis:
[Dr. Lafita] The most important step in a sports injury diagnosis is the evaluation of medical imaging studies - which includes both the radiologist’s interpretation of the scan as well as the report they write for the case.
This means that selecting the right, qualified radiologist to read your scan is a critical component of ensuring an accurate diagnosis. If you have a general radiologist interpreting your scan when you need a specialist - there’s a much higher risk of misdiagnosis.
All too often, patients are unaware of who is reading their scans. For instance, you might get an MRI of your elbow and assume it’s being read by the best-suited radiologist (which, in this case, would be a musculoskeletal radiology specialist) when it’s actually being interpreted by a general radiologist with little to no MRI training. This can impact the accuracy of your diagnosis - and you might not even know!
It’s similar to what I explained about the initial clinical exam a doctor performs on a patient: a more specialized physician is likely to do specific tests that will allow them to come up with a more specific diagnosis than a generalist. The same goes for radiology specialists. And within subspecialty training, the type of training makes a difference.For sports injuries, a musculoskeletal (MSK) radiologist would be the appropriate subspecialist.
After studying different imaging techniques for one specific body system, the exposure and training allow a radiologist to become familiar with many different presentations of various conditions. It also gives them familiarity with normal variants that may or may not be clinically significant.
While certain sports medicine injuries usually result in specific patterns of diagnosis, things are not always black and white. There is a spectrum of findings that only a sports injury doctor and radiologist can spot. This enables them to give a more accurate diagnosis.