CAR - Canadian Association of Radiologists

The Canadian Association of Radiologists is the national specialty association for radiologists, dedicated to medical imaging excellence in patient care

You are here: Home / News / The CAR Collaborates with CWC and Medical Specialists on New MSK Recommendations

The CAR Collaborates with CWC and Medical Specialists on New MSK Recommendations

A new, multi-disciplinary project has put forward a set of recommendations for evaluating musculoskeletal (MSK) conditions with the aim of streamlining the medical imaging processes.

The CAR collaborated with Choosing Wisely Canada (CWC) and experts from a variety of medical specialties to put together their new MSK imaging recommendations.

Dr. Natalia Gorelik was a co-chair on the project with Dr. Kawan Rakhra and says it was critical work to undertake because patients undergoing imaging need to be sure they receive the appropriate test in a timely manner.

“Medical imaging is essential for diagnosing and managing many health conditions, yet a significant number of imaging studies fail to meet appropriateness criteria. These examinations can harm patients, overburden an already strained healthcare system, lengthen waitlists, drive up costs, and negatively impact the environment. As the Canadian healthcare system faces resource limitations and staffing shortages, optimizing medical imaging use has become critical,” she stressed.

A unique aspect of this project was its multi-disciplinary collaboration.

“These recommendations were developed through a collaboration involving clinical experts from various specialties, including radiology, orthopedics, rheumatology, and family medicine,” said Dr. Gorelik. “Using a structured, multi-step, consensus-based research methodology, experts assessed all scenarios from the CAR referral guidelines on MSK imaging to identify areas where imaging overuse was common and had a substantial impact on patients and the healthcare system.”

“Musculoskeletal injuries and diseases can present to be diagnosed and managed in various physician practices and settings. Thus, our process engaged physicians from the specialties of family medicine, emergency medicine, sports medicine, rheumatology, orthopedic surgery, and musculoskeletal radiology,” explained Dr. Rakhra. “Complex MSK pathologies may require a multi-disciplinary care approach such that different specialty physicians will need to utilize radiologic imaging to advance the care of their patients. As such, there is a need for mutually agreed upon, broad recommendations that can be implemented in all patient cases, by all physicians.”

Overall, Dr. Rakhra hopes the recommendations will lead to more optimal choices by physicians when using radiologic imaging studies to manage their patients’ conditions.

“The recommendations are peer expert developed, and physicians can confidently apply them in their clinical practices. This will minimize the ordering of low value studies, leading to more rapid diagnosis and management while reducing healthcare costs.”

This work was generously supported by the Canadian Radiological Foundation (CRF)/Canadian Heads of Academic Radiology (CHAR) Research Award.

MSK recommendations enews EN 2

Recommendations

1. Don’t order MRI without first considering ultrasound for the assessment of rotator cuff pathology and bursitis.

In adults with shoulder pain, if further investigation is required after the initial x-ray assessment, ultrasound is recommended as the next imaging modality for the evaluation of soft tissue pathology (such as rotator cuff tear, tendinopathy, effusion, bursitis, soft tissue calcification, or extra-articular impingement).

References

  • Hamel C, Avard B, Gorelik N, et al. Canadian Association of Radiologists Musculoskeletal System Diagnostic Imaging Referral Guideline. Can Assoc Radiol J. 2024; 75(2):269-278. doi: 10.1177/08465371231190807.
  • Weber S, Chahal J. Management of rotator cuff injuries. J Am Acad Orthop Surg. 2020;28(5):e193-e201. doi:10.5435/JAAOS-D-19-00463
  • Small KM, Adler RS, Shah SH, et al. ACR appropriateness criteria® shoulder pain-atraumatic. J Am Coll Radiol. 2018; 15(11S):S388-S402. doi:10.1016/j.jacr.2018.09.032
  • Sconfienza LM, Albano D, Allen G, et al. Clinical indications for musculoskeletal ultrasound updated in 2017 by european society of musculoskeletal radiology (ESSR) consensus. Eu Radiol. 2018;28(12):5338-5351. doi:10.1007/s00330-018-5474-3
  • The Royal College of Radiologists. RCR IRefer Guidelines: Making the Best Use of Clinical Radiology. London: The Royal College of Radiologists, 2017.

2. Don’t order MRI of the hip just based on x-ray features of femoroacetabular impingement unless there are clinical signs and symptoms of joint impingement.

If x-ray demonstrates imaging findings that may predispose to femoroacetabular impingement (FAI), then consultation to a musculoskeletal specialist is suggested as MRI may neither be required nor advance diagnosis or management.

References

  • Hamel C, Avard B, Gorelik N, et al. Canadian Association of Radiologists Musculoskeletal System Diagnostic Imaging Referral Guideline. Can Assoc Radiol J. 2024; 75(2):269-278. doi: 10.1177/08465371231190807.
  • Jawetz ST, Fox MG, Blankenbaker DG, et al. ACR Appropriateness Criteria® Chronic Hip Pain: 2022 Update. J Am Coll Radiol. 2023; 20(5): S33-S48. doi: 10.1016/j.jacr.2023.02.019
  • Reiman MP, Agricola R, Kemp JL, et al. Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International Hip-related Pain Research Network, Zurich 2018. BJSM online. 2018;54(11):631-641. doi:10.1136/bjsports-2019-101453
  • Mascarenhas VV, Castro MO, Rego PA, et al. The lisbon agreement on femoroacetabular impingement imaging-part 1: overview. Eur Radiol. 2020;30(10):5281-5297. doi:10.1007/s00330-020-06822-9
  • Mascarenhas VV, Castro MO, Afonso PD, et al. The Lisbon Agreement on femoroacetabular impingement imaging-part 2: general issues, parameters, and reporting. Eur Radiol. 2021;31: 4634-4651. Published online. doi:10.1007/s00330-020-07432-1
  • The Royal College of Radiologists. RCR IRefer Guidelines: Making the Best Use of Clinical Radiology. London: The Royal College of Radiologists, 2017.

3. Don’t order MRI of the hip or knee when x-ray demonstrates greater than mild osteoarthritis, unless recommended by a musculoskeletal specialist.

For patients with hip or knee pain likely related to degenerative joint pathology, if x-ray demonstrates greater than mild osteoarthritis, MRI may not be indicated as it often will not advance diagnosis or management. Musculoskeletal specialist consultation should be considered, to determine if MRI is required.

References

  • Hamel C, Avard B, Gorelik N, et al. Canadian Association of Radiologists Musculoskeletal System Diagnostic Imaging Referral Guideline. Can Assoc Radiol J. 2024; 75(2):269-278. doi: 10.1177/08465371231190807.
  • Fox MG, Chang EY, Amini B, et al. ACR appropriateness criteria® chronic knee pain. J Am Coll Radiol. 2018;15(11S): S302-S312. doi:10.1016/j.jacr.2018.09.016
  • The Royal College of Radiologists. RCR IRefer Guidelines: Making the Best Use of Clinical Radiology. London: The Royal College of Radiologists, 2017.