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Introduction

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Treat the patient, not the X-ray.

James M Hunter

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This chapter includes seven principles that may help clinicians maximize the utility of investigations, and which laboratory and special investigations add detail to the sports and exercise medicine diagnosis.

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Investigations

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Appropriate investigations can confirm or exclude a diagnosis suggested by the history and physical examination but should never be a substitute for careful history taking and a comprehensive examination (Chapter 11).

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1. Understand the meaning of test results

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The sports clinician should be able to interpret investigation results and not rely blindly on the investigation report. A clinician who knows that about a quarter of asymptomatic elite jumping athletes have ultrasound abnormalities in their patellar tendons can reassure the patient that the imaging finding is not an indication for surgery. This is an example of a false positive investigation. Many such examples exist.

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2. Know how soon changes can be detected by investigations

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To detect certain abnormalities, the timing of an investigation may need to be appropriate. A female gymnast must have hormone levels tested in the second half of her menstrual cycle to detect low progesterone levels in luteal deficiency. Likewise, there is nothing to be gained by repeating a radioisotopic bone scan or a CT scan to assess fracture healing two months after diagnosing a lumbar pars interarticularis defect in a tennis player.

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3. Only order investigations that will influence management

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It is inappropriate to perform extensive (and expensive) investigations to confirm an already obvious diagnosis. If a stress fracture is seen on a plain X-ray, there is rarely anything to be gained from an MRI scan.

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4. Provide relevant clinical findings on the requisition

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Accurate and complete clinical information on requisition forms helps to avoid imaging and reporting errors.1 When particular X-ray views are required they should be requested. If you cannot remember the names of certain views, write that down on the request forms—the radiographer will generally know and, if not, the radiologist will! It is often helpful to call the radiologist in advance to discuss the best way to image a patient. Remember that weight-bearing views are important to assess suspected osteoarthritis at the hip, knee, and ankle. “Functional” views (with the patient placing the joint in the position of pain) are useful for anterior and posterior impingement of the ankle (Chapter 39).

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5. Do not accept a poor quality test

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Inappropriate views or investigations performed on inferior equipment can lead to more diagnostic confusion than no investigation at all.

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6. Develop a close working relationship with investigators

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Optimizing communication between colleagues improves the quality of the service.1 Regular clinical-radiological ...

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