Musculoskeletal (MSK) radiology is booming, thanks, in part, to the dramatic increase in demand coming from the aging Baby Boom generation. Not only are people living longer, but they are remaining far more active for far longer than previous generations.

“Certainly, we’re seeing a lot of people of this generation who seemed to be active past the years that our parents were, so consequently, we are seeing a lot more injuries,” says Michael B. Zlatkin, MD, president of National Musculoskeletal Imaging PA and voluntary professor of radiology at the Miller School of Medicine, University of Miami, who believes the change goes beyond simply doing more for longer. “People are seeking out care for aches and pains that previous generations probably just ignored as part of the natural aging process. They are really not accepting the other ‘cure’—which is to slow down. Now, they know something is wrong, and they want to know if it can be fixed.”

Another side effect of this forever- young mentality is an increase in overuse, activity-related injuries. People who started jogging at age 30 and are now 60 have subjected their frames to three decades of abuse…and it shows.

“As a result, their knees have really worn down, and they may present with knee pain that doesn’t respond to conventional therapy,” says Stephen J. Pomeranz, MD, CEO and medical director of ProScan Imaging, Cincinnati, who recommends swimming, cycling, and other nonimpact workouts for his Baby Boomer patients who are eager to stay fit. “Activity is tremendous for people as they grow older, but what people need to realize is that the types of activities that their body allows differ at varying ages.”

In concert with injuries resulting from too much movement, MSK radiologists are imaging an increasing number of individuals whose complaints are generated from too little movement.

“In active patients, we see sports-related injuries; in sedentary patients, we see degenerative pathology and insufficiency fractures,” says Amilcare Gentili, MD, clinical professor of radiology in the musculoskeletal section, Department of Radiology, University of California, San Diego.

For the growing segment of the population that is overweight and often sedentary, concerns frequently involve the back and the knees—along with the general degenerative process that occurs from people carrying too much weight over an extended period of time.

“It’s more the presence of degenerative-type [problems]—[resulting from] wear and tear, like a meniscal tear, cartilage loss, rotator cuff tear,” Zlatkin says. “And, of course, back problems are very prevalent as you grow older—disk disease or stenosis and those sorts of [conditions]—and that tends to be very limiting.”

In addition to hampering a patient’s level of activity, back injuries could create actual problems. “Obesity and osteoporosis predispose a person to back pain and may lead to decreased activity, but people may become sedentary secondary to their underlying medical condition,” says Murray K. Dalinka, MD, chair of the American College of Radiology Panel on Musculoskeletal Imaging and professor of radiology and orthopedic surgery and head of musculoskeletal imaging at the Hospital of the University of Pennsylvania, Philadelphia. “Degenerative arthritis is probably more common in active patients, because, among other things, it is dependent upon use. But back pain is common in both active patients and sedentary individuals.”

Crunching the Numbers

Anyone who made their debut on the planet between 1946 and 1964 is generally thought to be part of the Baby Boom generation, a group of individuals accounting for a considerable portion of the nation’s population.

In 2006, the oldest Boomers will turn 60. With the average life expectancy increasing, the impact of these aging Americans is undeniable.

Some notable numbers from the US Census Bureau include:

  • as of July 2005, there were an estimated 78.2 million Baby Boomers;
  • this year, almost 8,000 people will turn 60 each day, an average of 330 every hour;
  • slightly more than half of the generation was female (in 2005);
  • each person between 45 and 54 years of age in 2004—what is generally considered to represent the “heart” of the Baby Boomers—spent an average of $2,695 on health care–related expenses. Boomers age 55 to 64 spent $3,262 and those 65 and over shelled out $3,899 each, on average, during the same year; and
  • in 2003, there were just slightly more than 4,000 continuing care retirement facilities operating in the country. By comparison, there were almost 28,000 fitness and recreation centers nationwide.

—D. Hinesly

Escalating Demand

In addition to a steady increase in patient volume, there has been a shift in the types of examinations being performed.

“CT is used much less frequently, but it is most useful for fractures, for looking at the positioning of devices, and in the angulation of fractures. So, CT still plays an important role in musculoskeletal care.” —Stephen J. Pomeranz, MD,ProScan Imaging

“The major effect is on the increased number of studies being ordered for these elderly people, along with a continued increase in demand for imaging,” Dalinka says. “Frequently, there is a shift to more complex studies and/or an addition of the complex studies to standard radiography, including an increased demand for MRI examinations, particularly of the spine, knee, and shoulder, as well as an increased use of CT.”

Across the country, the primary modalities employed by MSK radiologists are CT and MR. For many clinicians, MR is the first line of defense, taking the lead as the modality of choice for MSK professionals.

Part of this growth is due to the technology’s ability to produce exceptional results in a range of applications. MRI is used for visualizing the shoulder for rotator cuff tears, the hip for occult fractures, the knee for meniscal tear and insufficiency fractures, and the ankle for tendinosis and tendon tears—in particular, the Achilles tendon, peroneal tendons, and posterior tibial tendons.

As well as helping radiologists perform diagnoses, MR also can indicate when an interventional procedure is not warranted or would not be beneficial to the patient.

“The aging population has wear and tear or overuse-related problems, such as arthritis,” Pomeranz says. “Very often, the arthritic condition is not amenable to intervention, but it is treated conservatively until the time comes when the patient needs a new joint. MR can show that the patient doesn’t have something that can be immediately fixable with a surgical intervention.”

“MRI is noninvasive, and there’s access to it, particularly in big cities … so it’s pretty easy to get yourself scanned.”—Michael B. Zlatkin, MD,National Musculoskeletal Imaging PA and Miller School of Medicine, University of Miami

Although MR receives the bulk of the attention, CT continues to be of great utility to MSK subspecialists.

“CT is used much less frequently, but it is most useful for fractures, for looking at the positioning of devices, and in the angulation of fractures,” Pomeranz says. “So, CT still plays an important role in musculoskeletal care.”

CT studies also are increasing in treatment of post-trauma patients to identify fracture or to detect the entire extent of involvement. Other procedures growing in popularity include vertebroplasty and kyphoplasty, relatively new procedures that are used in elderly patients with compression fractures secondary to osteoporosis, according to Dalinka. “Joint and spine MRI are used for a host of indications, and molecular imaging techniques will be developed to aid in diagnosis,” he predicts.

MR and CT have proven to be so powerful, they have begun to edge other, more-traditional approaches—such as bone scanning, thermography, and myelography—out of the picture.

New Approach,Old Problem

The availability of improved imaging technology is not lost on the general population. Thanks to the Internet and seemingly nonstop news coverage of the latest breakthroughs in medical and health issues, a growing level of self-education is occurring in the general patient population.

“The lay press is out there, and the Baby Boomers—and Generation X right behind them—are aware of these methodologies and know of people seeking them out for diagnosis and treatment,” Zlatkin says. For many patients, the prevailing assumption is that for every problem, an MRI scan is prescribed to identify the trouble. “If you tell patients that you want to wait 6 months to see if it goes away, they’ll tell you they want to know now so they can see if it is something bad that requires surgery.”

As MRI proliferates, the modality has become virtually irresistible to a generation of people working to age as gracefully as possible.

“Characteristically, patients don’t come directly to radiologists and ask about an MRI; they’re asking their orthopedic surgeons or their primary care providers—they know about the test even before they get to the doctor’s office,” Pomeranz says.

And for good reason. Few would argue against leaving the determination of the best test in the hands of the clinicians; however, MR systems provide access to diagnostic methods far beyond what was available in the past—in a safer, more patient-friendly way.

“For about 20 years, to figure out if there was a meniscal tear or a rotator cuff tear, you had to do arthrography or arthroscopy, but both are invasive, so people would avoid having that done if possible,” Zlatkin says. “MRI is non-invasive, and there’s access to it, particularly in big cities with freestanding imaging centers and MRIs in many offices, so it’s pretty easy to get yourself scanned.”

Other minimally invasive image-guided techniques have been introduced—such as kyphoplasty, vertebroplasty, and the injection of bone metastases for palliative purposes—and enable elderly and cancer patients to undergo procedures that were previously off-limits because of the risks inherent to surgical procedures and longer recovery times.

Help Wanted

Technology has been able to meet the needs of the aging population’s deteriorating skeletons; however, many in the industry feel there is a shortage of specialists who are best suited to interpret images and give diagnoses.

“Openings for musculoskeletal radiologists are in academic medical centers throughout the country, and many large practice groups want or need [them].”—Murray K. Dalinka, MD, American College of Radiology Panel on Musculoskeletal Imaging and the Hospital of the University of Pennsylvania, Philadelphia

“There probably are not enough experts in musculoskeletal radiology, and, of course, the more specialists we can get, the better it is,” says Pomeranz, who has seen the interest in ProScan’s MRI fellowship program grow steadily.

He is not alone. Dalinka says, “Although it depends on the region of the country and, in many cases, the demand of the clinicians, a lot of openings for musculoskeletal radiologists are in academic medical centers throughout the country, and many large practice groups want or need musculoskeletal radiologists. People call to ask about our trainees from the day they arrive, or even before, so there is a great demand for people who have had training in musculoskeletal radiology.”

Another dimension of this problem is the shortage of radiologists in general. To fill the need, teleradiology has become a financially advantageous approach to solving this dilemma, making it possible for in-demand subspecialists to interpret and diagnose from anywhere—a solution that is of growing importance to orthopedic surgeons.

“I think there’s a much greater awareness by the orthopedic surgeons of the level of expertise available, and if they have their choice, they prefer the images are read by a highly experienced, subspecialty musculoskeletal radiologist,” Zlatkin says. “And I think that’s best, too, in order to provide value [to the surgeons].”

Remote reading also holds much value for groups too small to support a full-time MSK radiologist, as well as making it possible for physicians to read night cases from home or have night cases read from a remote location through so-called nighthawk services.

To help provide quality care to patients, many larger radiology groups make teleradiology a central part of their business portfolio. For example, in addition to the 30 freestanding imaging centers that ProScan owns and operates, approximately half of the total number of readings come through teleradiology services provided to hospitals, clinics, freestanding imaging centers, and privately owned MRIs in Ohio and around the world.

“Orthopedists are a big market for teleradiology. Our practice is approximately 50% general radiology groups, 25% imaging centers, and 25% orthopedists.”—Amilcare Gentili, MD, University of California, San Diego

Qualified MSK radiologists have the opportunity to build a teleradiology business from a multitude of sources, providing this type of service to virtually any of their referring physicians.

“In our practice, orthopedic surgeons are the largest referrers, but we get referrals from primary care physicians, emergency room physicians, podiatrists, medical oncologists, and physical medicine and rehabilitation physicians,” says UCSD’s Gentili. “And I think orthopedists are a big market for teleradiology. Our practice is approximately 50% general radiology groups, 25% imaging centers, 25% orthopedists.”

New-breed Entrepreneur

The growing number of patients combined with the decreasing cost of technology has resulted in a growing number of orthopedists purchasing their own MR systems. The consensus seems to be that much of the motivation for owning a magnet stems from the desire to capture the associated technical fee, not necessarily to exclude the radiologist from the diagnostic process.

Whether the practice is a judicious one is a matter of great debate. One school of thought is that the critical issue is not where the images are captured, but where they are read.

“My position is that the expertise must be present to deliver health care,” Pomeranz says. “If you can deliver health care with a high level of expertise, with service, with caring, with passion—and of course, with the qualifications—then it should be,” Pomeranz says. “If the person reading has the expertise and happens to be next door, that’s terrific. But services like ours are available if that [ideal] doesn’t exist.”

Others argue that money is the wrong motivation for purchasing imaging technology.

“I am not in favor of it, because in the real world, the equipment is often purchased by people who do not do this on a routine basis, and price considerations often play a large role in the equipment purchased and in hiring who reads the studies,” Dalinka says. “In addition, multiple studies have shown that when the equipment is owned by nonradiologists, utilization increases, and many nonindicated studies are performed. This occurs in all age groups studied but is not always the case.”

Dana Hinesly is a contributing writer for Axis Imaging News.

Less Than Clear

Radiologists debate the usefulness of ultrasound for MSK

Using ultrasound to evaluate and diagnose musculoskeletal (MSK) injuries and other MSK conditions brings with it several practical advantages over the popularly used MR—specifically, the technology’s portability and, generally, its lower cost. Ultrasound also provides real-time capability and better spatial resolution.

“It’s probably best used for localization of fluid or cysts—differentiating between cystic and solid structures of that nature,” says Michael B. Zlatkin, MD, president of National Musculoskeletal Imaging PA and voluntary professor of radiology at the Miller School of Medicine, University of Miami. “Another area where I think it’s particularly useful is in invasive musculoskeletal radiology, where you may do injections into tendon sheaths because it’s a very good way to dynamically guide injections.”

A recent survey conducted by the Society of Skeletal Radiology (SSR), Schaumburg, Ill, and presented at this year’s annual meeting in Tucson, Ariz, found that 60% of respondents employed MSK ultrasound for image-guided interventional procedures, while more than half (55%) used it for diagnostic purposes. The survey included 63 responses, 38 of whom consider their institution as a university-affiliated teaching hospital.

The modality also can be ideal for viewing tendons and other muscle fibers. Ultrasound also serves as an alternative to MSK imaging of patients with contraindications for MR.

“Musculoskeletal ultrasound doesn’t really image the bone, but it does a very good job with the soft tissue. At our practice, we use ultrasound for rotator cuff disease, sometimes for Achilles tendon injuries, and, of course, for vascular applications like deep vein thrombosis or phlebitis,” says Stephen J. Pomeranz, MD, CEO and medical director of ProScan Imaging, Cincinnati, adding that ultrasound is preferred in situations where MR is not readily available. “The American culture is more focused on MR, but ultrasound is a very intensely used modality. If you go to another country, such as Australia, the population is much more heavily oriented toward ultrasound of the musculoskeletal system.”

Zlatkin echoes that sentiment. “In the United States, ultrasound hasn’t found the same acceptance that it has in Europe. Most Americans would ask for an MRI before they would ask for an ultrasound,” he says. “Ultrasound is an interesting tool, and it is being used as a niche, but it is certainly not as widespread as MRI.”

—D. Hinesly