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Last weekend, we all woke up to College Football Gameday on ESPN, or as I like to call it—Christmas morning! These games bring joy to many lives. Unfortunately, not all of the athletes finish contests with the same level of satisfaction… or health. High impact sports and increased physical demands inherently result in problems.

Many players fell victim to acute injuries from traumatic blows. As players limped off the field, I found myself guessing at orthopedic injuries. My differential diagnoses were significantly enhanced by instant replays that granted the opportunity to review the exact mechanism of an injury. As chiropractic physicians, we do not generally have the same luxury of playing back the precise moment injury; and traumatic events don’t happen in slow motion.

As radiographic imaging remains one the most fundamental ways to access an orthopedic injury, I found myself wondering: Which of those limping players would I x-ray? The decision to image a patient is not always straightforward. Luckily research helps guide this decision-making process.

Check out this week’s blog to watch an assessment of the most commonly injured joint and review the current imaging guidelines for the lower extremity and spine.

Watch the 13-minute expanded Facebook live including demonstrations of the essential orthopedic tests, functional evaluations, and imaging guidelines for the knee. Be sure to follow our page so you don’t miss any of our weekly live content.

The neck, knee, and ankle are the most common sites for acute athletic injury. Performing a detailed history and physical exam narrows the differential diagnosis. The use of clinical prediction rules and diagnostic clusters further illuminate the most probable diagnoses. However, when orthopedic tests are inconclusive, the history is not clear, the mechanism of injury doesn’t add up, or there are red flags— we must consider imaging to gather additional information.

What does the literature tell us concerning imaging for acute cervical injuries, knee pain, and ankle trauma? Here’s a quick refresher on the current imaging indications for these regions.


Cervical Spine Injuries (1)

X-ray if there is a positive finding in any one of the five categories below:


  1. The patient is NOT cognitively intact with neurological symptoms
  2. Age >65 years
  3. Fearful of moving head upon command
  4. Distraction-based injury
  5. Midline spine pain is present

Knee Injuries (2)

X-ray if there is knee pain AND any one of the four characteristics:


  1. Age >55
  2. Tenderness at the head of the fibula
  3. Isolated tenderness of the patella
  4. The patient cannot flex the knee to at least 90 degrees
  5. Unable to bear weight on the knee joint immediately after the injury for at least four steps

Ankle/Foot Injuries (3)

X-ray if ankle/foot pain AND any one of the following findings:


  1. Bone tenderness at the posterior aspects of the medial malleolus
  2. Bone tenderness at the lateral malleolus
  3. Bone tenderness at the base of the fifth metatarsal
  4. Bone tenderness at the navicular
  5. The patient was unable to bear weight on the joint immediately following the injury

It is important to remember not to image every patient who walks into your clinic. However, many patients should be imaged but are not.

“imaging was NOT performed where appropriately indicated in 65.6% of patients who presented with red flags, and 60.8% with clinical suspicion of severe pathology.” (4)

Performing appropriate x-rays protects you and your patients. The decision to image is not universally applied to all patients; as each patient is a case study of one.  Most patients visit you for problems that are not attributable to radiographic findings. The use of clinical prediction rules and diagnostic clusters generally yield correct diagnoses – many times, with the same specificity and sensitivity of imaging.

Most peer-reviewed recommendations cite 4-6 weeks of conservative care before imaging, in the absence of red flags or other concerning findings. But, if your clinical suspicion is high, never shy away from looking deeper sooner with imaging or additional diagnostic tests.

Don’t dig your head in the sand and shun imaging in every case. Over 60% of people with red flags or suspicious exam findings didn’t get imaged. Utilize tools like the guidelines above to ask the right questions and perform the best tests to assist your diagnostic process.

Speaking of guidelines…Download ChiroUp’s Imaging Infographic for a breakdown of your X-Ray or MRI findings. You’ll be able to easily educate your patients on the specific findings for their condition.

Did you know that ChiroUp subscribers have access to specific imaging recommendations per condition — and you can too! ChiroUp exists to streamline both provider & patient education in one easy-to-use system. The time to get started is NOW!

Visit our plans & pricing page to “Up” your game.

  1. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G, Reardon M, Holroyd B, Lesiuk H, Wells GA. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma N Engl J Med. 2003;349(26);2510-2518.
  2. Richman PB, McCluskey CF, Nashed A, et al. Performance of two clinical decision rules for knee radiography. J Emerg Med. Jul-Aug 1997; 15(4):459-463.
  3. Bachmann LM, Kolb E, Koller MT, Steuer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: a systematic review. BMJ. 2003; 326(7386):417.
  4. Jenkins HJ, et al. imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis The Spine Journal 2018

About the Author

Dr. Brandon Steele

Dr. Brandon Steele


Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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