DIAGNOSTIC IMAGING GUIDELINE FOR MUSCULOSKELETALCOMPLAINTS IN ADULTS - AN EVIDENCE-BASED APPROACH - PART 2

ORIGINAL ARTICLES

DIAGNOSTIC IMAGING GUIDELINE FOR MUSCULOSKELETAL
COMPLAINTS IN ADULTS—AN EVIDENCE-BASED
APPROACH—PART 2: UPPER EXTREMITY DISORDERS

André E. Bussières, DC,a Cynthia Peterson, DC, RN, MMedEd,b and John A.M. Taylor, DCc

ABSTRACT

Purpose: To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary
care providers in decision making for the appropriate use of diagnostic imaging for upper extremity disorders.
Methods: A comprehensive search of the English and French language literature was conducted using a combination
of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy
studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and
Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation
protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an
external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in
chiropractic radiology, clinical sciences, and research was invited to review and propose recommendations on the
indications for diagnostic imaging. The guidelines were pilot tested and peer-reviewed by practicing chiropractors and
by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence.
Dissemination and implementation strategies are discussed.
Results: Recommendations for diagnostic imaging guidelines of adult upper extremity disorders are provided,
supported by over 126 primary and secondary citations. The overall quality of available literature is low, however.
On average, 44 Delphi panelists completed 1 of 2 rounds, reaching over 88% agreement on all 32 recommenda-
tions. Peer review by specialists reflected high levels of agreement and perceived ease of use of guidelines and
implementation feasibility.
Conclusions: The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be
updated regularly. Future research is needed to validate their content. (J Manipulative Physiol Ther 2008;31:2-32)
Key Indexing Term: Diagnostic Imaging; Radiology, Diagnostic x-ray; Radiography; Practice Guideline; Guideline;
Adult; Musculoskeletal System; Pain; Upper Extremity; Shoulder; Elbow; Wrist; Hand; Trauma

REPORTING OF TOPICS INCLUDED IN THE DEVELOPMENT OF the pertinence of developing diagnostic imaging guidelines.
THE DIAGNOSTIC IMAGING PRACTICE GUIDELINES1 This initial review led to a research project divided into 9
phases: (1) literature search, (2) independent literature assess-
An initial literature review considered 10 clinical questions ment, (3) guideline development specific recommendations, (4)
pertaining to imaging of musculoskeletal conditions to evaluate first external review, (5) consensus panel (modified Delphi), (6)
public website, (7) second external review, (8) final draft and
a Professor, Chiropractic Department, Université du Québec à grading of the recommendations, and (9) dissemination and
Trois-Rivières, Québec, Canada. implementation. Details of this study are published elsewhere.2

b Professor, Canadian Memorial Chiropractic College, Toronto, FOCUS
Ontario, Canada.
These diagnostic imaging guidelines concern adult
c Professor of Radiology, D'Youville College, Buffalo, New musculoskeletal disorders of the upper extremities where
York. conventional radiography and specialized imaging studies
are deemed useful for diagnostic purposes.
Submit requests for reprints to: André Bussières, DC, Professor,
Département chiropratique, Université du Québec à trois-Rivières, OBJECTIVES
C.P. 500, Trois-Rivières, Québec, Canada G9A 5H7
(e-mail: [email protected]). Reasons for developing these guidelines include assisting
current and future health care providers to make appropriate
Paper submitted July 15, 2007; in revised form September 27,
2007; accepted October 14, 2007.

0161-4754/$34.00
Copyright © 2008 by National University of Health Sciences.
doi:10.1016/j.jmpt.2007.11.002

2

Journal of Manipulative and Physiological Therapeutics Bussières et al 3
Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

use of imaging studies, providing indications for the need of adapted by the Stroke Prevention and Educational
imaging studies according to current literature and expert Awareness Diffusion (SPREAD) group.5,7
consensus, and assisting in optimizing the utilization of
limited available resources. These proposed guidelines are PATIENT PREFERENCES
intended to reduce unnecessary radiation exposure and the Condition-specific imaging guidelines
use of specialized imaging studies, increase examination
precision and decrease health care costs–all without Integral to evidence-based health care, decisions regard-
compromising quality of care. ing the use of imaging studies should be based on the best
available evidence and the experience and judgment of the
TARGET USERS/SETTING clinician while considering patient preference. A public
member reviewed all documents and provided comments
Intended users of the guidelines are chiropractors and other and suggestions.
primary health care providers prescribing diagnostic imaging
studies. The setting in which these guidelines may be used STAKEHOLDERS AND EDITORIAL INDEPENDENCE
include private clinics, outpatient clinics, and hospital emer- Pre-release Review
gency departments.
Before the release of the guidelines, the reliability of
TARGET POPULATION proposed recommendations was tested on specialists both
in chiropractic and in medicine as well as on field
The patient population eligible for guideline recommen- chiropractors.
dations are adult patients presenting with musculoskeletal
disorders of the upper extremities. Children and pregnant Potential Conflict of Interest
patients are excluded from these guideline recommendations. The research team involved in the development of these

DEVELOPERS guidelines declares no existing or potential conflict of
interest. No investigators have received nor will receive
The proposed guidelines are developed from the results of 9 any personal financial benefits or derive any salary from
distinct phases overseen by a research team composed of the 3 this project.
investigators with postgraduate education from 3 independent
teaching institutions. The guidelines were further developed and Funding Sources/Sponsors
peer-reviewed by more than 60 chiropractic clinicians, 1. Canadian Memorial Chiropractic College Post Grad-
academics, researchers, and a group of physicians. uate Education and Research (2005)
2. National Institutes of Health Student Grant (2006)
EVIDENCE COLLECTION 3. Canadian Chiropractic Protective Association (2006)

Electronic searches in English and French language UPDATING/REVISION
literature occurred, and cross-references were repeated on 3
different occasions between 2003 and 2006. The literature review and the guidelines should be
updated every 2 to 3 years.

METHODS FOR SYNTHESIZING EVIDENCE POTENTIAL BENEFITS AND HARM

a) Literature search and independent literature assessment of Selection of appropriate radiological imaging procedures
spinal disorders: Quality of diagnostic accuracy studies for evaluation of patients with musculoskeletal disorders of
(QUADAS),3 Appraisal of Guidelines Research and the upper extremities; decrease unnecessary ionizing radia-
Evaluation (AGREE),4 and Stroke Prevention and tion exposure, decrease costs, and improve accessibility.
Educational Awareness Diffusion (SPREAD).5
DISSEMINATION/IMPLEMENTATION CONSIDERATIONS
b) Initial draft: template based on European Commission
classification (2001).6 Publication, applying to National Guideline Clearing-
house, Posting of the electronic document on various Web
c) Expert consensus: a 2-round modified Delphi process sites (malpractice insurance carriers, outpatient teaching
was used to generate consensus among an international clinics); educational intervention strategies (e-learning,
panel of over 60 experts in musculoskeletal disorders. community pilot studies); referral guidelines reinforced by
request checking and clinical management algorithms;
RECOMMENDATION GRADING CRITERIA promotion by national, provincial, and state organizations;
and conferences.
The evaluation tool used was designed by the
Scottish Intercollegiate Guidelines Network (SIGN) and

4 Bussières et al Journal of Manipulative and Physiological Therapeutics
January 2008
Diagnostic Imaging Upper Extremity Disorders

DEFINITIONS, PATIENT PRESENTATIONS, management has a reasonable probability to improve
RECOMMENDATIONS, AND RATIONALE patient outcomes.9-11

These topics are integral parts of each 1 of the 3 Investigators and collaborators in the development of
diagnostic imaging guidelines: lower extremity disorders, these imaging guidelines believe that liability insurance
upper extremity disorders, and spine disorders. Results of the companies, third party payers, and courts of law should not
9 phases of the research project are published elsewhere.2 rely solely on descriptions of patient presentations, proposed
recommendations, and/or corresponding comments found
PRELIMINARY CONSIDERATIONS AND DISCLAIMER throughout the documents, as patient presentations are unique
and the application of any guideline always requires clinical
What is the Role of These Guidelines? judgment and thus needs to be considered in the proper
These evidence-based diagnostic imaging practice context. In addition, laws and regulations may vary between
geographical regions and should be considered when
guidelines are intended to assist primary care providers applying the proposed indications for any imaging study.
and students in decision making regarding the appropriate
use of diagnostic imaging for specific clinical presenta- What is Evidence-Based Health Care?
tions. The guidelines are intended to be used in Evidence-Based is About Tools, Not About Rules.12 Evidence-based
conjunction with sound clinical judgment and experience.
For example, other special circumstances for radiographic health care is an approach in which clinicians and health
imaging studies may include: patient unable to give a care professionals utilize the current best evidence in
reliable history, crippling cancer phobia focused on back making decisions about the care of patients. It involves
pain, need for immediate decision about career or athletic continuously and systematically searching, appraising, and
future or legal evaluation, history of significant radio- incorporating contemporaneous research findings into
graphic abnormalities elsewhere reported to patient but no clinical practice. The overall goal is improving patient
films or reliable report reasonably available, and history of care through life-long learning.12,13
finding from other studies (eg, nuclear medicine or chest
imaging) that requires radiograph for correlation.8 Appli- Potential Disagreements
cation of these guidelines should help avoid unnecessary There are several reasons for disagreement within a
radiographs, increase examination precision, and decrease
health care costs without compromising the quality of care. guideline development group. These include differences in
interpretation of the research literature, differences in
The descriptions of clinical presentations and proposed personal experience, and different perceptions of the inherent
clinical diagnostic criteria, recommendations for imaging risks and benefits of a procedure.14 Divergent or competing
studies, and the comments provided throughout this docu- guidelines on similar topics serve only to further confuse and
ment are a synthesis of the vast body of literature consulted frustrate practitioners.15 In addition, the continued lack of
before and during the various phases of this research project. unity among chiropractors hinders its growth by limiting
Where the literature was found to be of poor quality or integration and cooperation within of the greater health care
absent, consensus based on expert opinion was used. system. Readers of any guidelines are advised to critically
Although the investigators and collaborators carefully evaluate the methods used as well as the content of the
searched for all relevant articles, it is probable that some recommendations before adopting them for use in practice.16
have been missed. Furthermore, as many new important
studies are published in the near future, these will be Standard Patient Management Activities
incorporated in subsequent revisions of the guidelines, and Standard patient management activities, including diag-
recommendations may change accordingly.
nostic assessment and follow-up, are integral components of
What These Guidelines Do and What They Do Not Do every patient encounter.17 Initial triage of patients with
These guidelines are intended to address issues faced by musculoskeletal disorders is a constant recommendation of
various clinical guidelines.18 Imaging studies are used most
first contact professionals only. These guidelines do not practically as confirmation studies once a working diagnosis
address all possible conditions associated with musculoske- is determined. The objective is to determine the presence of
letal disorders, only those that account for the majority of clinical indicators of serious pathologies (red flags) requiring
initial visits to a practitioner. diagnostic imaging, specialist referral, or urgent surgical
intervention. When a practitioner recommends that a radio-
Like other diagnostic tests, imaging studies should graph or other diagnostic imaging study be performed, and
only be considered if (a) they yield clinically important the patient refuses, the patient should be advised of the
information beyond that obtained from the history and associated risks and implications, and this should be
physical examination, (b) this information can poten- recorded in the patient's records.
tially alter patient management, and (c) this altered

Journal of Manipulative and Physiological Therapeutics Bussières et al 5
Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

Table 1. Adult Shoulder Disorders

Patient presentation Recommendations Comments

Adult patients with full or limited movement and non Radiographs not Most cases of acute shoulder pain are of “mechanical” origin and
traumatic shoulder pain of less than 4 wk duration40,41 initially indicated (B) can be managed as acute regional pain.41
Radiography is typically not useful for soft tissue disorders such
Information from the history may alert to the presence of a rare, as bursitis, tendinosis, capsulitis, glenoid cartilage tear,
underlying serious condition. The reliability and validity of myofascial pain syndrome, polymyalgia rheumatica, or referred
individual features in histories have low diagnostic pain. Referred pain from the neck is common. Other sources
significance. History, type of pain, and site of pain are the most include: chest wall, myocardium, and diaphragm.44
important features to direct the diagnostic strategy. Every age Shoulder pain cumulative lifetime prevalence is ∼10%, making
group exhibits typical specific shoulder problems and diseases. it the third most commonly experienced type of musculoskeletal
pain, exceeded only by low back and neck pain. The prevalence
A comprehensive assessment of shoulder outcomes would is highest in the 40-65–year age bracket, among women, manual
include a generic measure of health-related quality of life, workers and certain ethnic groups. Point prevalence is between
a shoulder-specific measure of function, and a measure of 6.9 and 26%, 1-mo prevalence is 18.6-31%, and 12-mo period
patient satisfaction.42 See Appendix C [A] for details prevalence is 16%-47%. Approximately 1% of the adult
population is expected to visit a general practitioner annually for
Physical examination is used primarily to discriminate shoulder pain and the incidence of reported shoulder complaint is
between articular involvement and referred pain. 19.0 per 1000 person-years. Fifty percent of acute shoulder pain
Examination should include the cervical spine, chest resolves in 8-10 wk, but as many as 40% of cases may be
wall and elbow joint. persisting for longer than 1 year.
In “well functioning” 70-79-year-old patients, neck and shoulder
Patients unlikely to require initial radiographic examination pain seem to occur in conjunction with pain in other joints and
if there is: no precipitating fall; no sudden onset of pain or comorbidity. Nearly 20% reported having some shoulder pain for
swelling; no palpable mass or deformity; no pain at rest; over 1-mo duration in the past year.41,44-48
and normal ROM (adapted from Fraenkel 2000—
prospective validation needed)43

Poorer prognosis is associated with increasing age, female sex,
severe or recurrent symptoms at presentation, higher shoulder
disability score, and associated neck pain. A more favorable
prognosis is associated with mild trauma or overuse before
onset of pain, early presentation and acute onset.44,45

See Appendix C [B]. Factors predicting chronic shoulder pain
and risk factors for long-term employee absenteeism.

General indications for radiographs include40,41,44,49 If radiographs are Critical exclusionary diagnoses include:
• No response to care after 4 wk. indicated51: (C) • Osteonecrosis

• Significant activity restriction N4 wk 1. AP internal rotation • Septic arthritis

• Non mechanical pain (unrelenting pain at rest, constant or 2. AP external • Acute fractures and avulsion fractures

progressive symptoms and signs, pain not reproduced rotation • Malignant tumors

on assessment) 3. Axillary view • Pain radiating from the chest (myocardial ischemia)

• Red flags indicators: 4. Y-scapula view

○ Hx of cancer, S&S of cancer, unexplained deformity, Additional views: To visualize lung apices if suspect referred pain from pulmonary

palpable enlarging mass, or swelling, age N50 y, pain at PA chest view, disease such as Pancoast's tumor or if referred from the neck
rest, pain at multiple sites, unexplained weight loss, cervical spine AP Grashey view: looks directly down the glenohumeral joint78

significant unexplained shoulder pain with no previous and lateral views Early access to specialized investigations is unlikely to improve

films (tumor?) Grashey view management of a heterogeneous group of shoulder disorders
that should usually be managed conservatively.44
○ Red skin, fever, systemically unwell, immunosupression,

penetrating wound, underlying disease process (infection?)

○ History of noninvestigated trauma, epileptic seizure, Special investigations Specialist referral and specialized imaging recommended

electrical shock, loss of mobility in undiagnosed condition, not initially indicated: even if conventional radiographs are unremarkable if

loss of normal shape (unreduced dislocation? (B) there is6,41,43,44,49-57:

Glenohumeral instability?) (see “Glenohumeral instability" • Pain and significant disability lasting over 6 mo,

and “Adult patients with significant shoulder/glenohumeral despite attention to occupation and sporting factors

joint trauma") • In the absence of clinical improvement after 4 wk of therapy

○ Trauma, acute disabling pain and significant weakness, • If function does not improve or deteriorates

positive drop arm test (acute rotator cuff tear?) • History of instability or acute, severe post-traumatic

○ Unexplained significant sensory or motor deficit acromioclavicular pain

(neurological lesion?) • In presence of a potentially serious pathology as suggested

N. B. Presence of a red flag alone may not necessarily indicate by the patient history, examination and/or radiograph.

the need for radiography. Most patients with chronic The choice of imaging modality can be based on factors such

shoulder pain can be adequately evaluated with as the importance of ancillary clinical information (regarding

history, physical examination, and then started on lesions of the glenoid labrum, joint capsule, or surrounding

a treatment protocol. muscle and bone), the presence of an implanted device, patient

If this treatment fails to relieve the symptoms tolerance, and cost.

within 4 wk, advanced imaging with MRI may • MRI is a sensitive diagnostic tool in secondary care and may
be indicated.50 increase specificity of Dx. MRI provides best imaging details

6 Bussières et al Journal of Manipulative and Physiological Therapeutics
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Diagnostic Imaging Upper Extremity Disorders

Table 1 (continued) Recommendations Comments

Patient presentation for evaluation of shoulder pathology (osteonecrosis, marrow
and joint disease including infection) but is rarely used in the
Glenohumeral joint disorders acute setting.
Global pain and restriction of all activities and passive • While cost-effective, ultrasonography is operator-dependant;
mostly useful for full-thickness rotator cuff tears
movements, restricted passive external rotation • CT is useful for characterizing fractures if more information is
needed (can show fracture complexity, displacement and
angulation)
Chest CT: in case of suspected Pancoast's tumor, CT of the
chest is optimal

Consult specific clinical diagnoses and related patient Radiographs not Radiological analysis in conditions such as subacromial
impingement, pathologies of the rotator cuff, and
presentations for additional help in decision making. initially indicated acromioclavicular degeneration should be interpreted in the
context of the symptoms and normal age-related changes.
Specific clinical diagnoses: (D) Degenerative changes including sclerosis of the medial end of
1. Rotator cuff disorders (tendinopathy)40,44,58 Early radiograph the acromion and the distal end of the clavicle, inferior acromial
and clavicular osteophytes, partial and full thickness tears are
MC cause of shoulder pain. if soft tissue commonly found during imaging of asymptomatic people.44,64
Most patients with rotator cuff disorders are older.
Acute: any age; chronic usually N40 YOA calcification is Ruling out suspected comorbidities is important.Radiographs of
subjects with a documented rotator cuff tear may
• History may reveal occupational heavy lifting, or expected. have greater tuberosity abnormalities (sclerosis, osteophytes,
subchondral cysts and osteolysis) not seen in asymptomatic
repetitive movements, especially above shoulder subjects without a rotator cuff tear.64 Large lateral
extension of the acromion appears to be associated with
level; genetic susceptibility in some families If radiographs are full-thickness tearing of the rotator cuff.65
Potential causes of primary impingement that may be assessed
• Pain on abduction with thumb down, worse against indicated (D) with radiographs include specifically: inferior A-C osteophytes
and the type 3 acromion.
resistance and painful arc (70°-120°) 1. AP internal rotation 1. Y-scapula view may show hooked (type 3) acromion
2. In those with history of A-C joint disease or old trauma, A-C
• No history of dislocation, instability, surgery, violent 2. AP external rotation
joint view may be part of the workup to R/O bony
trauma, or other shoulder disorder 3. Axillary view impingement 58
Classified according to its clinical progression59: Additional view:
A. Impingement is a dynamic process that may be assessed by US
I Acute inflammation (tendinitis/bursitis) Y-scapula or A-C B. Rotator cuff full and partial thickness tear: MRI, US are highly
accurate for full-thickness tears but much less sensitive and
II Degeneration/chronic inflammation (tendinitis) joint views specific for partial tears. MRA improves diagnostic accuracy.
The size of rotator cuff tear and degree of fatty muscle
III Rupture and arthritis degeneration appears to have the most pronounced influence on
acromiohumeral distance. Quality of available studies on US is
A. Impingement: night pain, upper arm pain and tenderness, variable.6,40,52,66-70
C. Calcifying bursitis within cuff tendons: calcifying bursitis can
cuff weakness, atrophy, painful arc, painful crepitation. cause severe pain. If conservative treatment fails, consider MRI
and referring patient for calcium puncture aspiration under
High-sensitivity tests (0.8): Neer, Hawkins, horizontal fluoroscopy guidance.71

adduction, Jobe, impingement sign and painful arc

High-specificity tests (0.8): drop arm test, Yergason, speed,
passive external rotation52,60,61

*Physical examination for impingement syndrome, superior labral
tears and rotator cuff tear equally effective as US or MRI59

Differential Dx includes calcific tendinitis, cervical Special investigations

radiculitis and viral plexopathy (C)

B. Rotator cuff tear: traumatic in young people and MRI is gold standard.

atraumatic in elderly; there is strong evidence that Routine preevaluation

clinical tests are able to R/O full tears but have does not appear to
questionable value for partial tears:52 3 positive tests have significant effect

or 2 if N60 YOA is predictive of a tear: supraspinatus on treatment outcome.
weakness, external rotation weakness, Hawkins.62,63

See Appendix C [C] for proposed risk factors for upper In addition, abnormal

extremity tendinopathy including personal, psychosocial, rotator cuff appearance

physical, and systemic risk factors. in asymptomatic

patients N60 YOA is
around 54%.40,50,64

2. Adhesive capsulitis (frozen shoulder) Radiographs not Radiographs are generally nonspecific (osteopenia may be
• Onset typically between the ages of 40-65 y routinely indicated present); a focal medial indentation along the proximal humeral
• Progressive deep joint pain and stiffness of spontaneous (D) neck has been reported for adhesive capsulitis. Radiographs are
not generally useful to diagnose adhesive capsulitis, but may be
onset and restricted activities such as dressing Special investigations used to exclude complicating factors.72
(D) • MRI with direct or indirect arthrogram to be considered before
• N50% Loss of passive abduction and external rotation,33 manipulation; thickness of capsule and synovium of the axillary
usually loss of all ROM, pain at end range, no recess N3 mm appears to be useful criterion for the Dx of
local tenderness adhesive capsulitis on coronal oblique T2-weighted MRA

(continued on next page)

Journal of Manipulative and Physiological Therapeutics Bussières et al 7
Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

Table 1 (continued)

Patient presentation Recommendations Comments

Usually idiopathic, but may follow prolonged images without fat suppression73,74
immobilization, neck surgery, systemic disorders Consider medical referral for distended arthrogram75 or
(diabetes), radiation therapy, and cerebral insult intra-articular corticosteroid injection under fluoroscopy
if conservative therapy fails.59

3. Osteoarthritis (DJD) Radiographs Outcome from treatment not predicted by use of radiography
Usually ≥60 years old, progressive pain, crepitus, indicated if: (D) Possible radiographic findings: humeral osteophytes, narrowed
• Unrelieved by 4 wk joint space, irregularity of the humeral head, subchondral cysts,
decreased end-ROM, tender joint and sclerosis at the greater tuberosity in rotator cuff arthropathy
Specific causes: rotator cuff arthropathy, after anterior of conservative care Supraspinatus outlet view for hooked acromion
• Suspected or osteophytes76,77
dislocation, arthritis, chondrocalcinosis, syringomyelia,
systemic disease (RA or AS), primary osteoarthritis underlying specific
(rare), osteonecrosis cause (pathology)
Osteonecrosis risk factors that can then lead to DJD: 1. AP internal rotation
prolonged glucocorticoids, anabolic steroid abuse, 2. AP external rotation
humeral head fracture, systemic lupus 3. Axillary view
erythematosus, sickle-cell anemia59 4. Y-scapula view
Additional view:
Supraspinatus
outlet view

4. Glenohumeral joint inflammatory arthritis Radiographs Although uncommon, the glenohumeral joint may be involved in
Involved in most forms of inflammatory arthritis indicated (D) most forms of inflammatory arthritis. In RA, erosions are usually
1. AP internal rotation a late feature.
(RA, gout, reactive arthritis [Reiter's], JRA, AS)40,49 2. AP external rotation Grashey view: looks directly down the glenohumeral joint78
Critical differential Dx: septic arthritis 3. Axillary view
Suspected septic arthritis: prompt referral for joint Additional view: Advanced imaging and rheumatologist referral recommended:
Grashey view • In suspected septic arthritis, consider MRI promptly
aspiration recommended for Dx and treatment Special investigations
(D/GPP) for complete assessment of glenohumeral joint, preferably
with intra-articular gadolinium.

5. Glenohumeral instability40,79 Radiographs Radiologic findings may be normal or reveal signs of
Bankart lesion, Hill-Sachs deformity, loss of joint space.
Usually between the ages of 20 and 35 y, Hx of dislocation indicated (D) or an anteroinferior glenoid calcification. Neither prereduction
nor postreduction films are likely to affect management
or subluxation, positive apprehension sign 1. AP internal rotation in emergency departments of patients with recurrent
dislocation by an atraumatic mechanism.54,83
Generalized ligamentous laxity (in multidirectional and 2. AP external Acute anterior and posterior dislocation should be referred to an
orthopedic specialist even if shoulder is reduced. The arm should
voluntary instability) rotation be placed in a simple sling. It should be noted that some
Several types (categories): 3. Axillary view51 practitioners with specialized training such as sports or
orthopedic diplomates can manage recurrent dislocations.
Anterior (MC) 4. Y-scapula view Some also handle first-time dislocations.

Posterior (dislocation often not recognized) Advanced imaging and specialist referral recommended:
• In the acute setting, conventional MRI nicely shows
Multidirectional
labral, Bankart, ligamentous, and tendinous injuries that
Voluntary or habitual instability (may be associated with result from dislocations and can lead to instability. In the
setting of chronic instability, MRA best evaluates these
psychological disorders) lesions. In the postoperative shoulder, multislice CT
arthrography may be the modality of choice, but further
Clinical assessment of joint position; excessive glenohumeral investigation is needed.84
• Glenoid labrum and synovial cavity well delineated by
translation produces apprehension, pain, or dysfunction: Special investigations arthrogram with CT and with MRI.40,85 Gradient-echo MRI
can show labrum without arthrography or proton density
Although not very sensitive, the anterior drawer, the (C) fat saturation protocols.6,40

apprehension, and the surprise tests are specific and predictive

of traumatic anterior instability. Apprehension is a better

criterion than pain. The relocation test adds little to the value of
the tests.80,81 Positive results suggest involvement of the
anterior or the superior glenoid labrum, respectively.82

Tears of the labrum, the capsule, or the glenohumeral
ligaments can lead to pain, catching, popping or instability.
The evidence suggests that clinical tests have moderate
sensitivity and specificity for instability and labrum
tears (quality of studies questionable)52

Dislocation may result in rotator cuff tears in middle-age or
older age groups. Patients may show ongoing symptoms of
pain, weakness, and dysfunction.

See Levine and Flatow62 for additional reading

8 Bussières et al Journal of Manipulative and Physiological Therapeutics
January 2008
Diagnostic Imaging Upper Extremity Disorders

Table 1 (continued)

Patient presentation Recommendations Comments

Adult patients with significant shoulder/glenohumeral Radiographs • R/O fracture-dislocation in blunt trauma and concurrent nerve
injuries, especially with anterior dislocation
joint trauma40,44 indicated (B)
• Common occult fractures include avulsion (“flap”) fractures of
Radiographic examination is appropriate if there is trauma 1. AP neutral view the greater tuberosity (tubercle).

sufficient to produce fracture or dislocation with accompanying (do not move the Y-scapula view: to visualize shoulder dislocation and fracture of
the scapula; some dislocations may present subtle signs.
signs/symptoms compatible with fracture or dislocation. shoulder) Additional views should be taken if fracture is suggested but not
found on initial views.
• Loss of normal shape, palpable mass or deformity 2. Y-scapula view
Advanced imaging and specialist referral recommended:
• Examination is unable to localize anatomical structure (lateral in scapular Repeat films in 10 days if a fracture remains a possibility after
responsible for patient symptoms. plane) normal initial evaluation or refer for CT scan. Callus formation or
abnormal alignment may be present.88
• Severely restricted shoulder mobility 3. Axillary view • MRI provides best imaging details for evaluation of shoulder
• History of epileptic seizure or electrical shock (if possible)51
pathology but is rarely used in acute setting.
Shoulder pain clinical decision rule* (adapted Additional view:x • US and CT arthrography both have a role in soft tissue injury
from Fraenkel43) transthoracic lateral
evaluation.
Patients unlikely to require initial radiographic

examination if there is: Special

1. No precipitating fall and no swelling, palpable mass or investigations40,49

deformity; (D)

2. A fall, but no swelling, palpable mass or deformity, and

no pain at rest

3. A fall and pain at rest, but no swelling, palpable mass

or deformity and normal ROM

Clinical decision rule in suspected shoulder dislocation may
include* 86:

• First-time dislocation

• Blunt trauma (fall N1 flight of stairs, assault, or motor

vehicle crash)

• When the clinician is uncertain of the joint position

Clinical decision rule in suspected fracture-dislocation may
include*87:

• First-time dislocation

• Blunt trauma (fall N1 flight of stairs, a fight/assault episode,

or a motor vehicle crash

• Age N40 y

*Prospective validation needed

A-C joint disorders Radiographs not The A-C joint is most commonly affected by osteoarthritis,

Teenage to 50 y of age. Usually secondary to trauma or initially indicated in posttraumatic arthritis, and distal clavicle osteolysis.

osteoarthritis. Pain localized to the A-C joint and non traumatic Degenerative changes of the A-C joints are common
possible swelling.4 origin (C) in the asymptomatic population.40,64,89

A. Acute A-C joint injuries have a limited differential Dx. If radiographs To exclude an A-C joint separation. Determine normal variation

Traumatic A-C joint injury frequently occurs with other indicated (D) in movement from injured side. There is no real benefit of

fractures, dislocations, or soft tissue injury around the AP view in a 15° conventional radiography for types I, II, and III A-C joint

shoulder. Look for joint deformity, swelling and cephalic angulation, dislocations as they confirm the obvious and are normally treated

tenderness, superior clavicular pain, pain with cross Stress radiographs conservatively. Types IV, V, and VI A-C joint dislocations should

body adduction. (bilateral comparison)57 be referred to an orthopedic surgeon after conventional

Critical differential Dx includes fracture/dislocation, vascular radiography.90,91

or neurological injuries and gross deformities of A-C joint The value of stress views remains uncertain.

suggesting high-grade injury.

B. Chronic injuries of the A-C joint also clearly diagnosed by Conventional radiography may also help exclude

appropriate physical examination and radiographs. Injury posttraumatic osteolysis in “Weight lifter's shoulder.”

to 1 shoulder component predisposes to other shoulder Special investigations Conventional radiography is insensitive to A-C joint degenerative
injuries. A thorough examination may reveal other (D) changes compared to MRI.92 Reactive bone edema on MRI is a more
associated abnormalities that may not be part of the
presenting complaint. Suspected isolated arthritis reliable predictor of symptomatic A-C joint pathology than
(sequela of type II A-C joint injury)
C. Impingement syndrome associated with inferior A-C degenerative changes seen on MRI and, when correlated with clinical
osteophytes and type 3 acromion may be assessed examination, is reproducible.90 MRI also allows assessment of adjacent
using plain films soft tissue structures and their effect on the underlying rotator cuff.92

• CT/MRI useful for pathological/surgical cases, especially in

separations of types IV-VI as vascular/ neurological

complications can result.
• US if CT and MRI not available93

Journal of Manipulative and Physiological Therapeutics Bussières et al 9
Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

Table 2. Adult Elbow Disorders

Patient presentation Recommendations Comments
The incidence of elbow complaints is ∼7.2 per
Adult patients with full or limited movement and non Radiographs not initially 1000 patients per year and the reported 12 month
period prevalence is 11.2% in the Netherlands. Elbow pain
traumatic elbow pain of less than 4-wk duration indicated (C) accounts for 2%-3% of total lost workdays and 5%-6%
of workers' compensation claims.47,94
The 2 important diagnoses to consider are lateral and Conventional radiographs usually nondiagnostic for:95
• Chronic epicondylitis
medial epicondylitis. Elbow complaints seldom occur in • Suspected nerve entrapment or mass, collateral ligament
tear, biceps tendon tear and/or bursitis
isolation. Patients often complain of neck, shoulder, Conventional radiographs may be diagnostic for:95
• Osteochondral fractures
arm, or hand problems as well. A complete examination • Intra-articular osteochondral body (IAB)
• Osteochondritis dissecans
of the upper extremity, including the cervical spine, • Heterotopic calcification of the ulnar ligament
is recommended.47,94
Advanced imaging and specialist referral recommended
See Appendix C for proposed risk factors for upper even if conventional radiographs are unremarkable if
there is:95,96
extremity tendinopathy including personal, • Pain and significant disability despite attention to
occupation and sporting factors
psychosocial, physical, and systemic risk factors. • In the absence of clinical improvement after 4 wk of
therapy
General indications for radiographs include40,41,49,95-97: Indicated before other • If function does not improve or deteriorates
• History of instability or acute, severe posttraumatic injury
• No response to care after 4 wk; imaging studies (B) AP • In presence of a potentially serious pathology as suggested
by the patient history, examination, and/or radiograph
• Significant activity restriction N4 wk; in full extension, lateral The choice of imaging modality can be based on factors
such as the importance of ancillary clinical information
• Non mechanical pain (unrelenting pain at rest, constant at 90° and medial (regarding lesions of the ligament, tendon, muscle, and
nerve, or other soft-tissue abnormality such as masses about
or progressive symptoms and signs, pain not reproduced oblique views the elbow joint), the presence of an implanted device,
patient tolerance, and cost.
on assessment) Additional views: • High-field-strength MRI provides greater detail than mid-
field or low-field MR systems. CT and US may be more
• Red flag indicators AP in pronation optimal than a low-field magnet in evaluation of the
elbow.96
○ Hx of cancer, S&S of cancer, unexplained deformity, Tangential (axial) • There is a lack of studies showing the sensitivity and
specificity of MRI in many of these cases.95
palpable enlarging mass, or swelling, significant
Advanced imaging and specialist referral recommended:
unexplained elbow pain with no previous films (tumor?) Special investigations (C) When the etiology is uncertain and the patient has failed
appropriate conservative therapeutic trial (see
○ Red skin, fever, systemically unwell (infection?) recommendation above)95,97

○ History of non-investigated trauma, loss of mobility in

undiagnosed condition, loss of normal shape

(unreduced dislocation? instability?)

○ Trauma, acute disabling pain and significant weakness

○ Unexplained significant sensory or motor deficit

(neurological lesion?)

N. B. Presence of a red flag alone may not necessarily

indicate the need for radiography.

Chronic elbow pain in the adult patient95,97 Radiographs indicated
(C)
May be caused by a variety of osseous abnormalities, AP in full extension,
soft-tissue abnormalities, or both; exclusion of an lateral at 90° and
abnormality with radiographs may be helpful when medial oblique views
conservative therapy is planned. In some cases, the Additional views (C)
films may reveal the underlying cause (eg,
intra-articular osteocartilaginous body, AP in pronation
hydroxyapatite deposition or calcium Tangential (axial)
pyrophosphate crystal deposition)
Special investigations (C)

10 Bussières et al Journal of Manipulative and Physiological Therapeutics
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Diagnostic Imaging Upper Extremity Disorders

Table 2 (continued)

Patient presentation Recommendations Comments

Specific clinical diagnoses: Radiographs not initially Elbow radiographs are generally unremarkable in lateral
1. Lateral epicondylitis (tennis elbow) indicated (C) epicondylitis; although up to 20% of patients can
have calcification in the area of the epicondyle.95,97
Epicondylar pain and tenderness at the elbow laterally Special investigations The incidence of lateral epicondylitis is 1%-3% in the
AND pain on resisted wrist extension—Cozen test: Sn: not indicated (C) general population, generally affecting older men, but the
0.73; Sp: 0.9795,98 prevalence in high-risk groups is as high as 15%, with
Differential diagnoses include lateral collateral ligament women N40 YOA commonly affected. Lateral epicondylitis
tear, radiocapitellar joint instability, bursitis, synovitis, results in an average of 12 wk of absenteeism in as many as
arthritis, chondromalacia, osteochondritis dissecans, 30% of persons afflicted.47,95
stenosis of the orbicular ligament, anconeus • MRI and CT are usually not necessary in the clinical
compartment syndrome, posterior interosseus nerve
or radial nerve radiculopathy, and radial tunnel evaluation of lateral epicondylitis.94,99 MRI may be
syndrome.95 helpful for confirming refractory cases and to exclude
associated tendon and ligament tear.95
2. Medial epicondylitis (Golfers' elbow) Radiographs not
initially indicated Elbow radiographs are generally unremarkable in medial
Epicondylar pain and tenderness at the elbow medially (C) epicondylitis, although up to 25% of patients can have
AND pain on resisted wrist flexion.100 calcification in the area of the epicondyle.94,101
Special investigations The prevalence of medial epicondylitis in a work population
Differential diagnoses include medial collateral ligament not indicated (C) ranges from 4%-5% with an annual incidence estimate of
instability or tear, ulnar trochlear synovitis, 1.5%, accounting for 10%-20% of all epicondylitis Dx94
chondromalacia, arthritis, and cervical radiculopathy.94 • MRI and CT are usually not necessary in the clinical

Adult patients with localized elbow pain after trauma1 Radiographs indicated evaluation of medial epicondylitis. MRI may be helpful
(C) for confirming refractory cases and to exclude associated
Elbow extension test: the inability to fully extend the AP in full extension, tendon and ligament tear.95
lateral at 90° and medial
elbow is a reliable indicator of osseous/joint injury oblique views57 Conventional radiography remains the mainstay of imaging
(Sn: 0.97; Sp: 0.69)102 when evaluating elbow trauma. Injury may result from
Instability tests—lateral pivot-shift apprehension Additional views (C) direct trauma or force that is transmitted axially from the
AP in pronation wrist and forearm.104
test (most sensitive), lateral pivot-shift test, Tangential view (axial) Routine reevaluation is not indicated in cases of joint
posterolateral rotary drawer test, stand up test103 Lateral stress view effusion without evidence of fracture.6,40
To reveal joint effusion, fracture/dislocation (look for a
Special investigations displaced anterior fat pad outward from the humerus
(GPP) [“sail sign"]). A significant joint effusion is associated
with a radial head fracture in 80% of cases. A visible
posterior fat pad should be considered a radial head
fracture until proven otherwise.
• MRI is increasingly used for the determination

of associated injuries of the lateral and medial
collateral ligaments and cartilage

Diffuse non-specific pain in the forearm (or wrist) Radiographs not initially Proximal causes of forearm and wrist pain such as cervical
indicated (D) spine and brachial plexus disorders need to be considered.
Pain in the absence of a specific Dx (sometimes includes: Electrodiagnostic studies may be useful if pain of
peripheral origin.
loss of function, weakness, cramp, muscle tenderness,
allodynia, slowing of fine movements)100

Forearm pain following trauma Radiographs indicated (D) Typically, imaging of the forearm is limited to conventional

Forearm views should be ordered when there is suspicion of radiography. Common fractures include Colles', (distal radius

abnormality to the mid portion of the radius or ulna. AP and lateral views. and ulna), Smith's (reverse Colles' fracture), Galeazzi's

Suspected trauma to either the wrist or elbow requires (fracture-dislocation of the distal radius/ulna), nightstick
views of the involved anatomical region.100,103,104
fracture (mid ulnar shaft fracture), and Monteggia fracture
(proximal ulnar shaft fracture and displaced radius).104

Journal of Manipulative and Physiological Therapeutics Bussières et al 11
Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

Table 3. Adult wrist and hand disorders Recommendations Comments
Radiographs not initially
Patient presentation indicated (D) The reported 12 month period prevalence of wrist and
hand pain symptoms is 17.5% in the Netherlands.47
Adult patients with non traumatic localized wrist If radiographs are indicated (C) Ganglion cysts occur 70% of the time on the dorsum of
and hand pain symptoms105,106 PA, lateral, and medial oblique the wrist but can occur on the volar region in the area of
views of the wrist or hand the trapeziotrapezoid joint. Imaging is generally not
Obtaining a thorough history is essential. Age should Additional views: helpful.108
be considered, particularly when evaluating chronic Radial and ulnar deviation views
wrist pain, because there is a direct relationship or clenched fist views are reserved Conventional radiography should be the study of
between age and cartilage and ligament attrition.107 for more subtle problems107 choice and can identify many areas of pathology.

Standard views of the wrist (flexed fingers) differ from Special investigations (D) Critical differential Dx:
standard views of the hand (fanned fingers). The combination of standard • Osteonecrosis
radiographs and US can diagnose • Septic arthritis
General indications for radiographs a wide variety of disorders.110 • Osteomyelitis
include40,41,49,106,109: MRI is the procedure of choice to • Acute fractures and avulsion fractures
exclude osteonecrosis, marrow and • Malignant tumors
• No response to care after 4 wk joint disease including
• Significant activity restriction N4 wk infection.111 Careful Hx, physical examination, radiograph, US and
• Nonmechanical pain (unrelenting pain at rest, bone scan usually establish a Dx (definite Dx in 60%,
probable Dx in 20%). Additional imaging (arthrography,
constant or progressive symptoms and signs, pain MRI and CT) increased definite Dx to 80%.100,112
not reproduced on assessment)—eg, Keinbock's
disease Advanced imaging and specialist referral
• Red flag indicators recommended:
○ S&S of cancer, unexplained deformity, palpable Some lesions cannot be detected by US (carpal
enlarging mass, or swelling, significant unexplained ligaments and triangular fibrocartilage tears as well as
wrist pain with no previous films (tumor?) cartilage and bone marrow disease) and require
○ Red skin, fever, systemically unwell (infection?) advanced modalities (CT, MRI, CT arthrography, and
○ History of noninvestigated trauma, loss of mobility MRA).100,106,110
in undiagnosed condition, loss of normal shape • MRI may be useful for TFCC lesions, carpal
(unreduced dislocation? Instability?) ligamentous injuries such as the scapholunate and
(see ‘Acute wrist trauma') lunotriquetral ligaments, ulnar impaction syndrome,
○ Trauma, acute disabling pain and significant occult fractures, bone marrow abnormalities, and soft
weakness tissue abnormalities but lack sensitivity or accuracy for
○ Unexplained significant sensory or motor deficit cartilage defects in the distal radius, scaphoid, lunate,
(neurological lesion at the wrist?) or triquetrum.113,114
○ Suspected associated inflammatory arthropathies • CT to evaluate osseous and articular morphology,
of wrist and hand. healing, cysts, and tumors
Specific indications for radiographs include106: • Bone scan may be useful in assessing AVN and
• Non-investigated chronic wrist and hand pain neoplasm.104
• Multiple sites of DJD as visualized on radiographs
• Possible TFCC abnormality
• Possible wrist instability, including perilunate
instability, dorsal and volar intercalated segmental
instability, scapholunate advanced collapse,
scapholunate dissociation, ulnar translocation of
the wrist104-106,109 (see ‘Acute wrist trauma')
• Possible operative candidate

See Appendix C [C] for proposed risk factors for upper
extremity pain and sickness absence including personal,
psychosocial, physical, and systemic risk factors.

Consult clinical presentation with related specific clinical
diagnoses for additional help in decision making.

Specific clinical diagnoses: Radiographs not initially There is poor evidence to suggest secondary signs on
indicated (D)
1. Tendinopathy of the wrist imaging unless associated with arthropathy.
Tendinosis* and paratendinitis** (stenosing If radiographs are indicated (D)
PA, lateral, and medial oblique Consider conventional radiography, in persistent
tenosynovitis) are responsible for most clinical views of the wrist painful “soft tissue injuries,” not only to exclude
disorders of tendons in the upper extremity.115 bony injury but also to aid Dx of rare cases of acute
The Dx of tendinopathy is based primarily on the history
and physical examination. Pain and tenderness over a spontaneous calcific peritendinitis of the hand and
specific tendon or tendon group are the hallmarks of this wrist.116
condition. Other findings include localized swelling,
impaired function, crepitus, pain with passive stretching While 60% of all cases of tendinopathy are not work
of the tendon, and positive provocative testing. related,56 a significant increase in the number of
Tendinosis, however, can be asymptomatic.94
successful work related claims is reported in several
countries.117

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Diagnostic Imaging Upper Extremity Disorders
Comments
Table 3 (continued) Recommendations
Proposed physical risk factors94,100,117:
Patient presentation Radiographs not initially Repetitive, forceful, radial deviation of the wrist with
indicated (D) abduction and extension of the thumb and rapid
* Tendinosis: intratendinous degeneration (commonly rotational movements of the forearm with repetitive
caused by aging, microtrauma, vascular compromise) movement and forceful ulnar deviation at the wrist.
Associated activities and occupations for De
** Paratendinitis: inflammation of the outer layer of the Quervain's include prolonged piano-playing, sewing,
tendon (paratenon) alone. knitting, and weaving, carrying heavy object, farm
labor, working on a grinding or buffing machine.
2. De Quervain's tenosynovitis 2(stenosing Nonoccupational risk factors include RA and hormonal
tenosynovitis or tenovaginitis) changes associated with pregnancy and menopause.

The MC tendinopathy in the wrist predominantly • Some studies have explored the use of high-
affecting women (10 times more then men), aged 30- resolution US and MRI, but further studies are
50 y; remains a clinical Dx with no indication for needed to validate these techniques.104
routine imaging.94
MC nerve compression disorder of the upper extremity.
Pain over the radial styloid and tender swelling of first Prevalence of 3% among women and 2% among men.
Peak prevalence among females ≥55 YOA.119
extensor compartment and either pain reproduced by Proposed risk factors100,117:

resisted thumb extension or positive Finkelstein's test. Jobs with repetitive forceful gripping; high force and
Associated symptoms include warmth and crepitus.100 high frequency of repetition; vibration tools; activities
that frequently flex or extend the wrist
Special investigations (D)
Sensory and motor nerve conduction studies have a
Differential diagnoses include: osteoarthritis of the relatively high sensitivity and modest specificity to
assess/document functional status of neurological
1st carpometacarpal joint, Wartenberg's syndrome, elements.121,122

Kienbock's disease, triscaphoid arthritis, and • Advanced imaging reserved for patients with
intersection syndrome.94 equivocal presentation or with diabetes and diffuse
peripheral neuropathy that confounds electro-
∼1/3 of patients may have associated conditions, such diagnostic studies.123 MRI may be used to image
anatomical abnormality (eg. space-occupying lesion
as cervical spondylosis, CTS, ganglion, trigger such as a ganglion).114 US may be a useful
fingers, lateral epicondylitis, and RA.94 alternative.57 High-resolution sonography may
show median nerve enlargement and accentuated
3. Carpal Tunnel Syndrome (CTS)100,118,119 Radiographs not initially hypoechogenicity.124
Clinical examination and electrodiagnostic studies have indicated (C)
It is common to have incomplete concordance between
been considered the gold standard for Dx of CTS. pathological changes, radiographic and clinical features
in OA.
Pain or paraesthesia or sensory loss in median nerve
distribution in at least 2 of the first 4 fingers (Se: (continued on next page)
0.83; Sp:0.45) and either one positive Tinel's (Sn:
0.34; Sp: 0.84, positive PV: 62%, positive LR: 2.3)
or Phalen's test (Sn: 0.56-0.63, Sp:0.72-0.83,
positive PV: 60%, positive LR: 2.0), Thenar
atrophy (Sn: 0.12, Sp:0.99, positive PV: 91%,
positive LR: 13), female gender, obesity
(BMI≥30), worsening of symptoms at night/
awakening, or abnormal nerve conduction time.

Clinical prediction rule (level IV)120: Special investigations (D)
1. Age N45 y
2. Shaking hands for symptom relief
3. Reduced median sensory field of thumb

4. Wrist-ratio index (carpal canal volume) N.67
5. SSS score (Brigham and Women Hospital) N1.9

Likelihood of CTS increase with no. of positive tests
(18.3 or 90% when all 5 tests positive)

4. Osteoarthritis Radiographs not initially
MC locations—1st carpometacarpal joints, distal indicated (D)

interphalangeal joints. Less commonly , triscaphe

(scaphoid-trapezium-trapezoid) and at the wrist (post
traumatic), radiocarpal.100

History:
• N50 YOA
• Morning joint stiffness b30 min

Journal of Manipulative and Physiological Therapeutics Bussières et al 13
Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

Table 3 (continued) Recommendations Comments

Patient presentation

Physical examination:
• Crepitation
• Bony tenderness
• Bony enlargement
• No palpable warmth

Other characteristics include: long-standing pain, no
extra-articular symptoms; non-responsive to NSAID
or corticosteroid medication; relieved with rest;
deformity or fixed contracture, joint effusion;
insidious onset.125

5. Inflammatory or crystal induced Radiographs indicated (C) Findings consistent with inflammatory arthritis:
arthropathy40,100,126 PA, lateral, and medial oblique of erosions of periarticular/articular surfaces and intra-
Gout, CPPD, etc (excluding RA) the wrist and hand articular radiodensities associated with erosion and
joint effusion
Dx of inflammatory arthritis is primarily based on
history and physical examination: Critical differential Dx100:
• Septic arthritis
• Unrelenting morning stiffness N30 min • Osteomyelitis
• Pain at rest
• Pain or stiffness better with light activity Special investigations (C) Advanced imaging and specialist referral

(during remission) recommended even if conventional radiographs
• Polyarticular involvement, especially the hands
• Palpable warmth are unremarkable:
• Joint effusion • If routine radiographs are normal or nondiagnostic,
• Diffuse tenderness
• Decreased ROM MRI is the study of choice.40,128 biopsy/aspiration to
• Fever/chills or other systemic symptoms R/O infection.106
• Responsive to NSAID or corticosteroid • Gadolinium-enhanced MRI of the hand and wrist is a

medication superior technique for detection of tenosynovitis in
• Flexion contracture in long standing arthritis. inflammatory arthritis.129

See Kainberger et al127 for imaging strategies
for baseline documentation of polyarticular
involvement.

6. RA40 Radiographs indicated (C) Findings consistent with inflammatory arthritis:
Symmetrical polyarticular involvement of wrist, PA, lateral, and medial oblique erosions of periarticular/ articular surfaces and intra-
views of the wrists and hands articular radiodensities associated with erosion and
metacarpophalangeal and proximal interphalangeal (Norgaard's/ball catcher joint effusion.
finger joints. projection)133
Radiographs of the hands, feet, and chest are
The total number of affected joints increases over the recommended at the initial evaluation. Radiographs
1st year of illness.100 of the feet and hands should be repeated annually for
the first 3 y of disease evolution, and thereafter as
The evaluation and monitoring of RA should be based deemed appropriate.130
on a systematic evaluation of a minimum set of In suspected RA, feet radiographs may show erosions
parameters including joint pain and inflammation, even when symptomatic hand (s) appear normal in
the patient's global assessment of pain, global 23-36% of cases in first 2-3 y of disease.130
assessment of disease, functional disability, acute Cervical spine involvement occurs in over half of
phase reactants, and radiologic evidence of patients with RA and atlantoaxial subluxation
damage.130 (AAS) develops in over 12% of patients with
RA. There is a strong correlation between a Larson
RA diagnostic criteria (≥4 of 7 required)131,132: erosion score for hand and wrist joint damage N50,
• Morning joint stiffness N1 h RA duration of N10 y, disease onset before age 50,
• Arthritis involving ≥3 joints for at least 6 wk number of previous disease modifying drugs and
• Hand arthritis (wrist, MCP, PIP) RA related surgery and AAS. It is important to
• Symmetric arthritis recognize that many patients acquire AAS in the
• Rheumatoid nodules first 3 y of their disease, but neurological
• Serum RH factor impairments develop after a mean period of 18 y
• Radiographic changes (range, 4-50 y).139-142

14 Bussières et al Journal of Manipulative and Physiological Therapeutics
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Diagnostic Imaging Upper Extremity Disorders

Table 3 (continued) Recommendations Comments

Patient presentation Special investigations40,134-136 (C) Advanced imaging and specialist referral
MRI highly sensitive and often recommended even if conventional radiographs
more specific than US; detection of are unremarkable:
synovial pannus, erosions, cartilage Unless aimed at some specific medical procedure,
loss, small subchondral cysts and special investigations should be minimized unless they
marrow edema distribution have some value for the patient.
MRI, US, and NM all show joint
effusion.137,138 • MRI is the modality of choice in early Dx and
management of RA.143 MRI helps differentiate
erosive from nonerosive disease.127

• US more sensitive to detect erosion

• NM more sensitive for suspected joint infection.
(osteomyelitis)135

7. Osteonecrosis (AVN) Radiographs indicated (C) Late effects of AVN may be seen on conventional
• Keinbock's disease is AVN with associated deformity PA, lateral, and medial oblique radiography with increased density.104

of the lunate bone. Special investigations (D) Advanced imaging and specialist referral
AVN is a potentially serious consequence of carpal MRI modality of choice to recommended:
evaluate bone marrow changes in MRI, CT, bone scan (high sensitivity but low
fracture, particularly of the scaphoid. early stages.114 specificity); gadolinium-enhanced MRI is considered
to be the best technique for detecting established
Nonmechanical pain144 AVN.114
○ Unrelenting pain at rest
○ Constant or progressive symptoms and signs
○ Pain not reproduced on assessment
○ Swelling, tenderness

8. Chronic Regional Pain Syndrome (CRPS)144 Radiographs indicated (D) Diffuse osteopenia seen in 70% of cases144
Synonyms: PA, lateral, and medial oblique
• Reflex sympathetic dystrophy syndrome Advanced imaging and specialist referral
• Sudek's atrophy Special investigations (D) recommended:
• MRI is useful in detecting numerous soft tissue and
At least 4 of the following must be present in order for a
Dx of CRPS to be made145: earlier bone and joint processes that are not depicted or
as well characterized with other imaging modalities.
Examination findings • 3-Phase NM scan recommended if radiograph is not
• Temperature/color change diagnostic (Sn: 0.10; Sp: 0.8; positive predictive
• Edema value: 54%; negative predictive value: 100%)145
• Trophic skin, hair, nail growth abnormalities
• Impaired motor function
• Hyperpathia/allodynia
• Sudomotor changes

Associated conditions:
• Fractures or other trauma
• CNS and spinal disorders
• Peripheral nerve injury

9. Suspected Triangular Fibrocartilage Complex Radiographs Indicated (D) Examine radiographs for ulnar variance, DJD of the
(TFCC*) lesion (articular disk)104 PA, lateral, and medial oblique104 distal radioulnar joint, instability of the lunate-
triquetrum or scapholunate areas, chondromalacia, of
Typically produces ulnar-sided wrist pain, which may the lunate or ulnar head, and either dorsiflexed or volar
become chronic and associated with clicking or flexed intercalated segmental instability.104
popping sounds with certain movements.

Lesions of the TFCC can be traumatic or degenerative, Special investigations (D) Advanced imaging and specialist referral
with the incidence of degenerative lesions increasing recommended:
with age. • MRI and Gadolinium-enhanced MRI.114

* The TFCC consists of the triangular fibrocartilage, the (continued on next page)
dorsal and palmar radioulnar ligaments, the ulnocarpal
meniscal homologue, the dorsal and palmar ulnocarpal
ligament, the sheath of the extensor carpi ulnaris
tendon and the capsule of the distal radioulnar joint.

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Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

Table 3 (continued) Recommendations Comments

Patient presentation Radiographs not initially A staging system for trigger finger has been proposed
indicated (D) based on the grade of mechanical involvement noted on
10. Stenosing Tenosynovitus (trigger finger of TF) examination: from normal finger movements (stage 1)
Intermittent, troublesome locking of the digit in to locked finger in flexion or extension (stage 6). Each
stage may be painless or painful. Essentially, only
flexion.100 digits locked in flexion require surgical intervention.96
Trigger finger is more common in women 40-60 YOA

and in patients with diabetes, RA, gout, and other
connective tissue disorders.146
The Dx is essentially clinical, radiographs are
unnecessary. Patients typically present with an
insidious onset of morning pain and snapping,
clicking, locking, or stiffness in the affected digit.
A painful nodule may be palpable at the distal
palmar crease. The nodule may move during active
movement.94

Acute wrist trauma in the adult patient40,104-106, 109, 147 Radiographs indicated (C) In females over 50 YOA, life time estimated risk of
PA, lateral and pronation-oblique osteoporotic wrist fractures is 16%71
The following evaluation helps predict or R/O fractures views (medial oblique) of the Fractures may not be visible at initial presentation;
when no deformity is present:148 wrist57 repeated films after 10-14 d if a fracture remains a
possibility or before proceeding with special
• Pain on passive and active motion A. Additional views (D) investigation.157
• Localized tenderness and edema 1. PA ulnar deviation (20°)149
• Pain with grip and resisted supination. 2. Lateral and oblique152 Because the wrist has a complicated anatomy with
A. Scaphoid fracture: many structures overlying each other (particularly on
Accounts for 70%-80% of all carpal fractures. MC in the lateral view), it is prudent, as in all other situations,
to have radiographs of traumatic wrist injuries carefully
young active males. Risks of non-union, arthrosis scrutinized by a radiologist to confirm that a pathologic
and AVN:149 condition has not been missed.104
• Anatomical snuffbox tenderness
• Longitudinal thumb compression
• Resisted supination
High sensitivity, specificity, and predictive value150,151

AVN and nonunion are potentially serious consequences
of carpal fracture, particularly of the scaphoid.

B) Suspected lunate instability: B. Additional views (D) In suspected carpal instability due to abnormally wide
Pain centered over the dorsal wrist immediately ulnar to Stress radiographs154,155 (include scapholunate space, consider adding palmar flexion and
dorsiflexion views of the wrist in the lateral projection
the extensor carpi radialis tendons PA w/ closed fist to stress scapho- on either conventional radiography or fluoroscopy.
Pain and abnormal movement noted on Watson test; lunate ligament)156 Search for proximal migration of capitate and opening
and closing of the scapholunate joint on radial and ulnar
* specialized testing may be indicated earlier in such 3. Maximal wrist extension and deviation views.158,159
case ulnar deviation153

Special investigations (C) Advanced imaging and specialist referral

recommended:
• Increasing use of MRI as only examination for*:

• Scaphoid fractures
• Pisiform and hamate
• Scaphotrapezium-trapezoid joint
• Scapholunate instability
* Nearly 100% sensitive and specific6,40,149
• CT scan is valid for demonstrating or ruling out a
scaphoid fracture and is superior to NM.160
• Consider bone scan (NM) in persistent cases of post

traumatic wrist pain even if repeat radiographs are

normal due to false negative rates of radiography for
carpal fracture.161

16 Bussières et al Journal of Manipulative and Physiological Therapeutics
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Diagnostic Imaging Upper Extremity Disorders

Table 3 (continued) Recommendations Comments

Patient presentation Radiographs indicated (D) Common fractures encountered in the hand include:
1. Hand: PA, lateral and Bennet's fracture, Rolando's fracture, Pseudo-Bennett's
Acute hand and finger trauma in the pronation-oblique fracture, Gamekeeper's thumb, Mallet finger, phalangeal
adult patient162 (medial oblique) fractures, Flexor digiturum profundus avulsion163

Traumatic injuries to the hand can be evaluated 2. Isolated finger: PA, lateral,
routinely by conventional radiography.104 pronation-oblique (AP for the
thumb)

Additional views: stress view of Stress view to identify gamekeeper's thumb (possible
the thumb (GPP) avulsion fracture of the proximal phalangeal base of the
thumb) is now considered contraindicated in case of a
Stener lesion.

Special investigations (D) Advanced imaging and specialist referral

recommended:
• Consider advanced imaging (MRI, US, or arthro-

graphy) in suspected Stener lesion (entrapment of
the ulnar collateral ligament) with gamekeeper's
fractures.164

Duration of Disorders presented in Appendix C. General indications for advanced
In clinical practice, musculoskeletal disorders are generally imaging are in Appendix D. Typical effective ionized
radiation dose for common imaging procedures are listed
divided into categories according to the duration of the patient in Appendix E. Further recommended reading pertaining to
complaint on initial presentation. These diagnostic imaging magnetic resonance imaging of the upper extremity is
guidelines therefore consider the following categories of offered in Appendix F.
clinical presentations: acute extremity disorder (b4 weeks
duration), subacute extremity disorder (4-12 weeks duration), Practical Applications
and persistent/chronic extremity disorder (N12 weeks • History taking and physical examination should be
duration). used to exclude red flags and serious injuries
(fracture and/or dislocation).
Are There Potential Risks Associated with Conventional Radiographs? • Physical examination is important for neurologic
Although somewhat controversial,19-22 it is important to screening and to discriminate between articular
involvement and referred pain.
remember that health hazards of all forms of radiation are • These guidelines may assist with diagnostic
cumulative.22-29 The Biological Effects of Ionizing Radiation triage (extremity pain with or without restric-
(BEIR VII) 2005 report released by the National Academy of tion of activity of daily living or presence of
Sciences adds further support to the “linear-no-threshold” red flags).
model of cancer risk from ionizing radiation exposure.30 In • Radiographs are not initially indicated for nonspe-
summary, this report concludes that ionizing radiation is cific shoulder, elbow, wrist, and hand pain.
dangerous even at low doses and that there are no safe limits. • Consider conventional radiography after blunt
Given the potential risks associated with conventional trauma, and if there is no improvement after
radiographs, only appropriate clinical indications can justify 4 weeks of conservative care or increasing
its use. In this regard, the need to confirm pathology, to follow disability.
the evolution of a pathology possibly affecting therapy, or to • Consider conventional radiography and specialized
identify a clinically suspected contraindication to manipula- imaging in the presence of red flags.
tive therapy are the best-documented reasons. The benefits of
all diagnostic studies must outweigh the risks and the inherent ACKNOWLEDGMENT
costs to the patient.9,31-39
We are appreciative of the efforts of the many people who
Tables 1-3 list the patient presentations, recommenda- assisted in this process, listed in Appendix G.
tions, and comments regarding diagnostic imaging for upper
extremity disorders. A list of abbreviations and glossary of
terms used in the recommendations is in Appendix A.
Appendix B provides a summary of the recommendations.
Pertinent information for upper extremity disorders is

Journal of Manipulative and Physiological Therapeutics Bussières et al 17
Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

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144. El-Khoury GY, Bennett DL, Dalinka MK, Daffner RH,
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peripheral nervous system—a review of the literature. Eur J loskeletal imaging. Chronic foot pain. Reston (VA): American
Neurol 2004;11:305-14. College of Radiology (ACR); 2005. p. 7. [online publication]
[58 references]. Available from: http://www.acr.org.
125. Salaffi F, Carotti M, Stancati A, Grassi W. Radiographic
assessment of osteoarthritis: analysis of disease progression. 145. Complex regional pain syndrome (CRPS). [online publica-
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126. Crawford CM, Caputo LA, Littlejohn GO. Clinical assess- http://www.guideline.gov.
ment in rheumatic disease—back to basic. Top Clin Chiropr
2000;7:1-12. 146. Saldana MJ. Trigger digits: diagnosis and treatment. J Am
Acad Orthop Surg 2001;9:246-52.
127. Kainberger F, Peloschek P, Langs G, Boegl K, Bischorf H.
Differential diagnosis of rheumatic diseases using conven- 147. Rubin DA, Dalinka MK, Daffner RH, DeSmet AA, El-
tional radiography. Best Pract Res Clin Rheumatol 2004;18: Khoury GY, Kneeland JB, et al. Expert Panel on Musculos-
783-811. keletal Imaging. Acute hand and wrist trauma. [online
publication]. Reston (VA): American College of Radiology
128. Jbara M, Patnana M, Kazmi F, Beltran J. MR imaging: (ACR); 2005. p. 8. [47 references]. Available from: http://
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and hand. Radiol Clin North Am 2006;44:625-42.
148. Cevik AA, Gunal I, Manisali M, Yanturali S, Atilla R,
129. Tehranzadeh J, Ashikyan O, Anavim A, Tramma S. Enhanced Holliman CJ. Evaluation of physical findings in acute wrist
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130. Clinical GUIPCAR Group. Clinical practice guideline for the 149. Schernberg F. Fractures récentes du scaphoïde (moins de trois
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151. Mehta M, Brautigan MW. Fracture of the carpal navicular– 158. Souza TA. Differential diagnosis and management for the
efficacy of clinical findings and improved diagnosis with six- chiropractor, Third Edition: protocols and algorithms. 3rd ed.
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152. Daffner RH, Emmerling EW, Buterbaugh GA. Proximal and 159. Lichtman DM, Gaenslen ES, Pollock GR. Midcarpal and
distal oblique radiography of the wrist: value in occult proximal carpal instabilities. In: Lichtman DM, Alexander
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A radiographic view of the Scaphotrapezium-Trapezoid joint. 160. Breederveld RS, Tuinebreijer WE. Investigation of computed
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154. Özçelik A, Günal İ, Köse N. Stress views in the radiography
of scapholunate instability. Eur J Radiol 2005;56:358-61. 161. Ivers RQ, Cumming RG, Mitchell P, Peduto AJ. The accuracy
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orthopaedics. Philadelphia, Pa: Elsevier; 2004. p. 38. 163. Helms CA. Fundamentals of skeletal radiology. 3rd ed.
Philadelphia, Pa: Elsevier Saunders; 2004. p. 235.
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Criteria. Radiology 2000;215(Suppl):375-8. p. 209.

APPENDIX A. LIST OF ABBREVIATIONS AND GLOSSARY FOR UPPER EXTREMITY DISORDERS

A-C joint: Acromio-clavicular joint

AP: Anteroposterior

AS: Ankylosing spondylitis

Osteonecrosis: Avascular necrosis

CPPD: Calcium pyrophosphate dihydrate crystal deposition disease

CNS: Central nervous system

CRPS: Complex regional pain syndrome

CT: Computed tomography

CTS: Carpal tunnel syndrome

DJD: Degenerative joint disease

Dx: Diagnosis

GHQ questionnaire: General Health Questionnaire History

IAB: Intra-articular osteocartilagenous body

JRA: Juvenile rheumatoid arthritis

MC: Most common

MRA: Magnetic resonance arthrography

MRI: Magnetic resonance imaging

NM: Nuclear medicine (bone scan)

PA: Posteroanterior

ROM: Range of motion

R/O: Rule out

RA: Rheumatoid arthritis

Sp: Specificity

Sn: Sensitivity

SSS: Symptom Severity Scale

Tendinosis: Degeneration of tendons and of tendon muscle attachments

TF: Trigger finger

TFCC: Triangular fibrocartilage complex

US: Ultrasound

X-ray: Plain film radiograph

YOA: years of age

N: Greater than

≥: Equal or greater than

ψ: psychology/psychiatry

22 Bussières et al Journal of Manipulative and Physiological Therapeutics
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Diagnostic Imaging Upper Extremity Disorders

APPENDIX B. SUMMARY OF RECOMMENDATIONS

Table 1. Summary of recommendations—adult shoulder disorders

Patient presentation Recommendations

Adult patients with full or limited movement and Radiographs not initially indicated (B)

nontraumatic shoulder pain of less than 4-wk duration

Patients unlikely to require initial radiographic examination

if: no precipitating fall, no sudden onset of pain or swelling,

no palpable mass or deformity; no pain at rest, and normal
ROM (adapted from Fraenkel et al 43—prospective

validation needed)

--------------------------------------------------------------
General indications for radiographs include: If radiographs are indicated (C)

• No response to care after 4 wk AP internal rotation, AP external rotation, axillary view, Y-scapula

• Significant activity restriction N4 wk view (lateral in scapular plane)

• Nonmechanical pain (unrelenting pain at rest, constant

or progressive symptoms and signs, pain not reproduced Additional views: PA chest view, cervical spine AP and lateral

on assessment) views, Grashey view

• Red flags indicators:

Most patients with chronic shoulder pain can be adequately Advanced imaging and specialist referral recommended even if

evaluated with a history, physical examination, and conventional radiographs are unremarkable if there is: (C)

plain radiographs. • Pain and significant disability lasting over 6 mo, despite attention

to occupation and sporting factors

• In the absence of clinical improvement after 4 wk of therapy

• If function does not improve or deteriorates

• History of instability, or acute, severe post-traumatic

acromioclavicular pain

• In presence of a potentially serious pathology as suggested by the

patient history, examination, and/or radiograph

Glenohumeral joint disorders Special investigations (B)
Consult specific clinical diagnoses and related patient presentations MRI, ultrasonography, CT

for additional help in decision making. Radiographs not initially indicated (D)
Early radiograph if soft tissue calcification is expected
Specific clinical diagnoses:

1. Rotator cuff disorders (tendinopathy)
MC cause of shoulder pain

Classified according to its clinical progression: If radiographs are indicated (D)
I. Acute inflammation (tendinitis/bursitis) AP internal rotation, AP external rotation, axillary view
II. Degeneration/chronic inflammation (tendinitis)
III. Rupture and arthritis Additional view: Neer's view (y-scapula) or A-C joint views

A. Impingement: night pain, upper arm pain and Special investigations (C)
tenderness, cuff weakness, atrophy, painful arc, MRI is gold standard.
painful crepitation
A. Impingement is a dynamic process which may be assessed
High-sensitivity tests (0.8): Neer, Hawkins, horizontal adduction, by US
Jobe, impingement sign and painful arc; B. Rotator cuff full and partial thickness tear: MRI, US, MRA
improves diagnostic accuracy
High-specificity tests (0.8): drop arm test, yergason, speed, passive C. Calcifying bursitis within cuff tendons: MRI
external rotation.
(continued on next page)
B. Rotator cuff tear: traumatic in young people and atraumatic
in elderly; there is strong evidence that clinical tests are able
to rule-out full tears but have questionable value for partial
tears: 3 positive tests or 2 if N60 YOA is predictive of a
tear: supraspinatus weakness, external rotation weakness,
Hawkins

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Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

Table 1 (continued) Radiographs not routinely indicated (D)

2. Adhesive capsulitis (frozen shoulder) Special investigations (D)
• Onset typically between the ages of 40-65 y • MRI with direct or indirect arthrogram
• Progressive deep joint pain and stiffness of spontaneous onset and • Distended arthrogram

restricted activities Radiographs indicated if (D)
• N50% loss of passive abduction and external rotation, usually • Unrelieved by 4 wk of conservative care
• suspected underlying specific cause (pathology)
loss of all ROM, pain at end range, no local tenderness AP internal rotation, AP external rotation, axillary view, Y-scapula
3. Osteoarthritis (DJD) view (lateral in scapular plane)
Usually ≥60 YOA, progressive pain, crepitus, decreased end-ROM,
Additional view: supraspinatus outlet view
tender joint Radiographs indicated (D)

4. Glenohumeral joint inflammatory arthritis AP internal rotation, AP external rotation, axillary view
Involved in most forms of inflammatory arthritis (RA, gout, reactive
Additional view: Grashey view
arthritis [Reiter's], JRA, AS)
Advanced imaging and specialist referral recommended (D/GGP)
5. Glenohumeral instability In suspected septic arthritis, consider MRI promptly for complete
Usually between the ages of 20 and 35 y, Hx of dislocation or assessment of glenohumeral joint, preferably with intraarticular
gadolinium
subluxation, apprehension sign Radiographs indicated (D)

Generalized ligamentous laxity (in multidirectional and voluntary AP internal rotation, AP external rotation, axillary view, Y-scapula
instability) view (lateral in scapular plane)

Adult patients with significant shoulder/glenohumeral joint Advanced imaging and specialist referral recommended (C)
trauma • Acute setting: conventional MRI
• Chronic instability: MRA
Radiographic examination is appropriate if there is trauma sufficient • Postoperative shoulder, multislice CT arthrography
to produce fracture, or dislocation, with accompanying signs/ Radiographs indicated (B)
symptoms compatible with fracture or dislocation.
AP neutral view (do not move the shoulder), Y-scapula view (lateral
• Loss of normal shape, palpable mass or deformity in scapular plane), axillary view (if possible)
• Severely restricted shoulder mobility Additional view: transthoracic lateral
• Examination is unable to localize anatomical structure responsible
Advanced imaging and specialist referral recommended (D)
for patient symptoms Repeat films in 10 days if a fracture remains a possibility after
• History of epileptic seizure or electrical shock normal initial evaluation or refer for CT scan. Callus formation or
abnormal alignment may be present.
Clinical decision rule in suspected shoulder dislocation may • MRI
include*: • US and CT arthrography

• First-time dislocation
• Blunt trauma (fall N1 flight of stairs, assault, or motor vehicle crash)
• When the clinician is uncertain of the joint position

Clinical decision rule in suspected fracture-dislocation may
include*:

• First-time dislocation
• Blunt trauma (fall N1 flight of stairs, a fight/assault episode, or

motor vehicle crash) or a motor vehicle crash
• Age N40 y

* Prospective validation needed

24 Bussières et al Journal of Manipulative and Physiological Therapeutics
January 2008
Diagnostic Imaging Upper Extremity Disorders
Radiographs not initially indicated in non traumatic origin (C)
Table 1 (continued)
If radiographs indicated (D)
A-C joint disorders AP view in a 15° cephalic angulation,
Teenage to 50 yoa; usually secondary to trauma or osteoarthritis;
Stress radiographs (bilateral comparison): the value of stress views
pain localized to the AC joint and possible swelling remains uncertain.

Special investigations (D)
• CT/MRI useful for pathological/surgical cases, especially in

separations of types IV-VI as vascular/neurological complications
can result
• US if CT and MRI not available

Table 2. Summary of recommendations—adult elbow disorders

Patient presentation Recommendations

Adult patients with full or limited movement and nontraumatic Radiographs not initially indicated (C)

elbow pain of less than 4 wk duration

--------------------------------------------------------------
General indications for radiographs include: Indicated before other imaging studies (B)

• No response to care after 4 wk AP in full extension, lateral at 90° and medial oblique views

• Significant activity restriction N4 wk Additional views: AP in pronation, tangential (axial)

• Non mechanical pain (unrelenting pain at rest, constant or

progressive symptoms and signs, pain not reproduced on Advanced imaging and specialist referral recommended even if

assessment) conventional radiographs are unremarkable if there is: (C)

• Red flag indicators • Pain and significant disability despite attention to occupation and

— Hx of cancer, S&S of cancer, unexplained deformity, palpable sporting factors

enlarging mass, or swelling, significant unexplained elbow pain • In the absence of clinical improvement after 4 wk of therapy

with no previous films (tumor?) • If function does not improve or deteriorates

— Red skin, fever, systemically unwell (infection?) • History of instability, or acute, severe posttraumatic injury

— History of noninvestigated trauma, loss of mobility in • In presence of a potentially serious pathology as suggested by the

undiagnosed condition, loss of normal shape (unreduced patient history, examination and/or radiograph

dislocation? Instability?) • High-field-strength MRI provides greater detail than mid-field or

— Trauma, acute disabling pain and significant weakness low-field MR systems.

— Unexplained significant sensory or motor deficit (neurological • CT and US may be more optimal than a low-field magnet in

lesion?) evaluation of the elbow.

Chronic elbow pain in the adult patient Radiographs indicated (C)
AP in full extension, lateral at 90° and medial oblique views
Specific clinical diagnoses:
1. Lateral epicondylitis (tennis elbow) Additional views: AP in pronation, tangential (axial)

Epicondylar pain AND tenderness at the elbow laterally AND pain Medical referral recommended and advanced imaging
on resisted wrist extension—Cozen test: recommended (C)
2. Medial epicondylitis (Golfers' elbow) When the etiology is uncertain and the patient has failed appropriate
Epicondylar pain AND tenderness at the elbow medially AND pain conservative therapeutic trials (see recommendation above).
on resisted wrist flexion.
Adult patients with localized elbow pain following trauma Radiographs not initially indicated (C)
Elbow extension test: the inability to fully extend the elbow is a Special investigations not indicated (C)
reliable indicator of osseous/joint injury
Radiographs not initially indicated (D)
Special investigations not indicated (C)

Radiographs indicated (C)
AP in full extension, lateral at 90° and medial oblique views

(continued on next page)

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Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

Table 2 (continued) Additional views (C): AP in pronation, tangential view (axial), lateral
stress view
Instability tests–lateral pivot-shift apprehension test (most sensitive),
lateral pivot-shift test, posterolateral rotary drawer test, and stand Special investigations (GPP)
up test • Increasing use of MRI for the determination of associated injuries of

Diffuse non-specific pain in the forearm (or wrist) the lateral and medial collateral ligaments and cartilage
Forearm pain following trauma
Radiographs not initially indicated (D)

Radiographs indicated (D)
AP and lateral views.

Table 3. Summary of recommendations—adult wrist and hand disorders

Patient Presentation Recommendations

Adult patients with nontraumatic localized wrist and hand pain Radiographs not initially indicated (D)

symptoms

--------------------------------------------------------------
General indications for radiographs include: If radiographs are indicated (C)

• No response to care after 4 wk PA, lateral, and medial oblique views of the wrist

• Significant activity restriction N4 wk

• Non mechanical pain (unrelenting pain at rest, constant or Additional views: radial and ulnar deviation views or clenched fist

progressive symptoms and signs, pain not reproduced on views are reserved for more subtle problems

assessment)—eg, Keinbock's disease

• Red flag indicators

○ S&S of cancer, unexplained deformity, palpable enlarging Special investigations (D)

mass, or swelling, significant unexplained wrist pain with no • The combination of standard radiographs and US can diagnose a

previous films (tumor?) wide variety of disorders.

○ Red skin, fever, systemically unwell (infection?) • MRI is the procedure of choice to exclude osteonecrosis, marrow,

○ History of noninvestigated trauma, loss of mobility in and joint disease including infection.

undiagnosed condition, loss of normal shape (unreduced

dislocation? Instability?) (Trauma section)

○ Trauma, acute disabling pain and significant weakness

○ Unexplained significant sensory or motor deficit (neurological

lesion at the wrist?)

○ Suspected associated inflammatory arthropathies of wrist and

hand

Specific indications for radiographs include:
• Noninvestigated chronic wrist and hand pain
• Multiple sites of DJD as visualized on radiographs
• Possible TFCC abnormality
• Possible wrist instability, including perilunate instability, dorsal

and volar intercalated segmental instability, scapholunate

advanced collapse, scapholunate dissociation, ulnar translocation
of the wrist—Trauma section
• Possible operative candidate

Consult clinical presentation with related specific clinical diagnoses Radiographs not initially indicated (D)
for additional help in decision making
If radiographs are indicated (D)
Specific clinical diagnoses: PA, lateral, and medial oblique views of the wrist
Consider conventional radiography, in persistent painful “soft tissue
1. Tendinopathy of the wrist injuries,” not only to exclude bony injury but also to aid Dx of rare
Pain and tenderness over a specific tendon or tendon group are the cases of acute spontaneous calcific peritendinitis of the hand and wrist
hallmarks of this condition. Other findings include localized
swelling, impaired function, crepitus, pain with passive stretching
of the tendon, and positive provocative testing. Tendinosis,
however, can be asymptomatic.

26 Bussières et al Journal of Manipulative and Physiological Therapeutics
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Diagnostic Imaging Upper Extremity Disorders
Radiographs not initially indicated (D)
Table 3 (continued)
Radiographs not initially indicated (C)
2. De Quervain's tenosynovitis (stenosing tenosynovitis or
tenovaginitis) Special investigations (D)
Advanced imaging reserved for patients with equivocal presentation
Pain over the radial styloid AND tender swelling of first extensor or with diabetes and diffuse peripheral neuropathy that confounds
compartment AND EITHER pain reproduced by resisted thumb electrodiagnostic studies
extension OR positive Finkelstein's test • MRI may be used to image anatomical abnormality (eg, space-
Associated symptoms include warmth and crepitus63
occupying lesion such as a ganglion).
3. CTS • US may be a useful alternative.
Pain OR paraesthesia OR sensory loss in median nerve distribution • High-resolution sonography may show median nerve enlargement

in at least 2 of the first 4 fingers AND either one positive Tinel's and increased hypoechogenicity
or Phalen's, Thenar atrophy, female gender, obesity (body mass
index ≥30), worsening of symptoms at night/awakening, or Radiographs not initially indicated (D)
abnormal nerve conduction time It is common to have incomplete concordance between pathologic
Clinical prediction rule (level IV): changes, radiographic and clinical features in OA.
1. Age N45 y
2. Shaking hands for symptom relief Radiographs indicated (C)
3. Reduced median sensory field of thumb PA, lateral, and medial oblique of the wrist and hand
4. Wrist ratio index (carpal canal volume) N.67 Special investigations (C)
5. SSS score (Brigham and Women Hospital) N1.9 • If routine radiographs are normal or nondiagnostic, MRI is the

Likelihood of CTS increase with number of positive tests (18.3 or study of choice; biopsy/aspiration to R/O infection
90% when all 5 tests positive) • Gadolinium-enhanced MRI of the hand and wrist is a superior

4. Osteoarthritis technique for detection of tenosynovitis in inflammatory arthritis
1. History: age N50 y, morning joint stiffness b30 min
2. Physical examination: crepitation, bony tenderness, bony Radiographs indicated (C) PA, lateral, and medial oblique views
of the wrists and hands 1(Norgaard's/ball catcher projection)
enlargement, no palpable warmth Radiographs of the hands, feet, and chest are recommended at the
initial evaluation
Other characteristics include: long standing pain, no extraarticular Special investigations (C)
symptoms; nonresponsive to NSAID or corticosteroid medication; • MRI is the modality of choice in early Dx and management of RA.
relieved with rest; deformity or fixed contracture, joint effusion;
insidious onset MRI helps differentiate erosive from nonerosive disease.
(continued on next page)
5. Inflammatory or crystal induced arthropathy (excluding RA)
Gout, CPPD, etc

Dx of inflammatory arthritis is primarily based on history and
physical examination:

• Unrelenting morning stiffness N30 min
• Pain at rest
• Pain or stiffness better with light activity (during remission)
• Polyarticular involvement, especially the hands
• Palpable warmth
• Joint effusion
• Diffuse tenderness
• Decreased ROM
• Fever/chills or other systemic symptoms
• Responsive to NSAID or corticosteroid medication
• Flexion contracture in long-standing arthritis

6. RA

Symmetrical involvement of wrist, metacarpophalangeal and
proximal interphalangeal finger joints

RA diagnostic criteria (≥4/7 required):
• Morning joint stiffness N1 h
• Arthritis involving ≥3 joints for at least 6 wk

Journal of Manipulative and Physiological Therapeutics Bussières et al 27
Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

Table 3 (continued) Radiographs indicated (C)
PA, lateral, and medial oblique
• Hand arthritis (wrist, MCP, PIP)
• Symmetric arthritis Special investigations (D)
• Rheumatoid nodules MRI modality of choice to evaluate bone marrow changes in
• Serum Rh factor early stages.
• Radiographic changes
Radiographs indicated (D)
7. Osteonecrosis (AVN) PA, lateral, and medial oblique

Nonmechanical pain Special investigations (D)
• Unrelenting pain at rest • MRI is useful in detecting numerous soft tissue and earlier bone
• Constant or progressive symptoms and signs
• Pain not reproduced on assessment and joint processes that are not depicted or as well characterized
• Swelling, tenderness with other imaging modalities
• 3-phase NM scan recommended if radiograph is not diagnostic
8. CRPS
Synonyms: Radiographs indicated (D)
• Reflex sympathetic dystrophy PA, lateral, and medial oblique
• Sudek's atrophy
Special investigations (D)
At least 4 of the following must be present in order for a Dx of CRPS MRI and gadolinium-enhanced MRI
to be made: Radiographs not initially indicated (D)

Examination findings Radiographs indicated (C)
• Temperature/color change PA, lateral and pronation-oblique views (medial oblique)
• Edema of the wrist
• Trophic skin, hair, nail growth abnormalities
• Impaired motor function A. Additional views (D) PA ulnar deviation (20°), lateral oblique,
• Hyperpathia/allodynia maximal wrist extension and ulnar deviation
• Sudomotor changes B. Additional views (D) stress tests (include PA with closed fist to
stress scapholunate ligament)
Associated conditions:
• Fractures or other trauma
• CNS and spinal disorders
• Peripheral nerve injury
9. Suspected TFCC lesion (articular disk)
Typically produces ulnar-sided wrist pain, which may become

chronic and associated with clicking or popping sounds with
certain movements

10. TF (stenosing tenosynovitis)
Intermittent, troublesome locking of the digit in flexion. More

common in women 40-60 YOA and in patients with diabetes,
RA, gout, and other connective tissue disorders

Patients typically present with an insidious onset of morning pain
and snapping, clicking, locking, or stiffness in the affected digit.
A painful nodule may be palpable at the distal palmar crease. The
nodule may move during active movement

Acute wrist trauma in the adult patient

The following evaluation helps predict or R/O fractures when no
deformity is present:
Pain on passive and active motion
Localized tenderness and edema
Pain with grip and resisted supination

28 Bussières et al Journal of Manipulative and Physiological Therapeutics
January 2008
Diagnostic Imaging Upper Extremity Disorders
Special investigations (C)
Table 3 (continued) Increasing use of MRI as only examination for:
• Scaphoid fractures
A. Carpal navicular (scaphoid) fracture: • Pisiform and hamate
Accounts for 70%-80% of all carpal fractures; MC in young • Scaphotrapezium-trapezoid joint
• Scapholunate instability
active males
Anatomical snuffbox tenderness Radiographs indicated (D)
Longitudinal thumb compression 1. Hand: PA, lateral and pronation-oblique (medial oblique)
Resisted supination 2. Isolated finger: PA, lateral, pronation-oblique

B. Suspected lunate instability: (AP for the thumb)
Pain centered over the dorsal wrist immediately ulnar to the
Additional views (GPP) Stress view of the thumb to identify
extensor carpi radialis tendons; pain and abnormal movement gamekeeper's thumb (possible avulsion fracture of the thumb
noted on Watson test. Specialized testing may be indicated proximal phalangeal base)
earlier in such case.
Special investigations (D)
Acute hand and finger trauma in the adult patient • Consider advanced imaging (MRI, US, or arthrography) in
Traumatic injuries to the hand can be evaluated routinely by
suspected Stener lesion (entrapment of the ulnar collateral
conventional radiography. ligament) with gamekeeper's fractures.

APPENDIX C. PERTINENT CLINICAL INFORMATION Job related mechanical exposure in both sexes is
associated with heightened risk for neck and shoulder
Shoulder disorders pain. In women, job strain, psychological job demands, and
A. Comprehensive assessment of shoulder outcomes low job decision latitude correlate with increased risk.c
A comprehensive assessment of shoulder outcomes
B. Factors predicting chronic shoulder pain and risk
would include a generic measure of health-related quality factors for long-term employee absenteeism.
of life, a shoulder-specific measure of function, and a
measure of patient satisfaction. The American Shoulder Factors predicting chronic shoulder pain may
and Elbow Surgeons (ASES) subjective shoulder scale has include the followingd:
overall acceptable psychometric performance (Test-Retest
Reliability, Internal Consistency, Content Validity, Criter- • Disability (independent of ROM)
ion Validity, Construct Validity, Responsiveness) for out- • Pain in a more narrowly defined region
come assessment in patients with shoulder instability, • Pain on examination
rotator cuff disorder, and glenohumeral arthritis.a • Symptoms lasting N1 year
• A high score on the GHQ
The ASES shoulder scale contains both a patient-
derived subjective assessment and a physician-derived Risk factors for long-term employee absenteeism
objective assessment. The subjective patient self-report may includee,f:
section consists of 2 equally weighted domains, pain and
function. Pain is recorded on an ordinal scale, ranging from • Excessive demands in the job
0 to 10, and accounts for 50% of the overall ASES score. • Repetitive movement
Function accounts for the other 50% of the overall score • Vibration duration during employment
and is divided into 10 questions with regard to difficulty • High psychological demands
with putting on a coat, sleeping on the affected side, • Poor control at work
washing the back or putting on a bra, managing toileting, • Poor social support
combing hair, reaching a high shelf, lifting 10 lb (4.5 kg) • Job dissatisfaction
above the shoulder, throwing a ball overhead, participating • Non–work-related stress reactions
in work, and participating in sports.b

Journal of Manipulative and Physiological Therapeutics Bussières et al 29
Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

C. Proposed risk factors for upper extremity d. Macfarlane GJ, Hunt IM, Silman AJ. Predictors
tendinopathy include the followingf,g: of chronic shoulder pain: a population based prospec-
tive study. J Rheumatol 1998; 25(8):612-5.
• Proposed personal risk factors
Sex, age (N40 years), obesity (body mass index e. van des Windt DA, Thomas E, Pope DP et al.
N30), and poor muscular conditioning. In addi- Occupational risk factors for shoulder pain: a systematic
tion, a complaint of baseline shoulder or neck review. Occupational and Environmental Med 2000;
discomfort, a history of carpal tunnel syndrome, 57:433-42.
and a job with a high shoulder posture rating are
related to tendinitis f. Bongers PM, Kremer AM, ter Laak J. Are
psychosocial factors, risk factors for symptoms and
• Proposed psychosocial risk factors: signs of the shoulder, elbow, or hand/wrist?: A review
Positive associations with high perceived job of the epidemiological literature. Am J Ind Med. 2002,
stress, high quantitative job demands, and low 41(5):315-42.
job control (few good-quality studies)
g. Wainstein JL, Nailor TE. Tendinitis and tendinosis of
• Proposed physical risk factors: the elbow, wrist, and hands. Clin Occup Environ Med
Tension overload and shear stress are 2 mechan- 2006; 5 (2) 299-322.
isms most likely responsible for most upper
extremity tendinopathies. Prolonged repetitive APPENDIX D. GENERAL INDICATIONS FOR ADVANCED
use (half to most of the time), exposed to IMAGING IN EXTREMITY DISORDERS
strenuous and/or repetitive work
Indications MRI CT NM US
• Proposed systemic risk factors:
Pregnancy, diabetes, rheumatoid arthritis, gout, Evaluation of neoplasm detected on ++ +
collagen vascular disease, Dupuytren's disease,
thyroid disease, amyloid, and chronic renal conventional radiographs
disease.
Determining skeletal distribution of neoplasms ++
References
or other multifocal skeletal disease
a. Kocher MS, Horan MP, Briggs KK, Richardson TR,
O'Holleran J, Hawkins RJ. Reliability, validity, and Internal joint derangements ++ + +
responsiveness of the American Shoulder and Elbow ++ ++
Surgeons Subjective Shoulder Scale in patients with Inflammatory arthritis + ++
shoulder instability, rotator cuff disease, and glenohumeral
arthritis. J Bone Joint Surg 2005; 87-A (9): 2006-2011. Evaluation of soft tissue injury, tendon pathology, ++

b. Richards RR, An KN, Bigliani LU, Friedman RJ, calcified bursitis
Gartsman GM, Gristina AG, Iannotti JP, Mow VC, Sidles
JA, Zuckerman JD. A standardized method for the Osteomyelitis ++ + ++
assessment of shoulder function. J Shoulder Elbow ++
Surg. 1994;3:347-52. Fluid collections or infections in joints or ++

c. Östergren PO, Hanson BS, Balogh I, Ektor-Anderson extra-articular soft tissues; unexplained soft
J, Isacsson A, Örbaek P, Winkel J, Isacsson SO. Incidence of
shoulder and neck pain in a working population: effect tissue mass
modification between mechanical and psychosocial expo-
sure at work? Results from a 1-year follow up of the Malmö Osteonecrosis ++ ++
shoulder and neck study cohort. J Epidemiol Community ++
health 2005;59:721-728. Complicated fractures + + ++
+
Suspected stress, occult fracture +

Complicated disease processes or findings +

unexplained by more conservative tests

++, first choice; +, second choice (must be determined on a case-by-
case basis)a,b,c

a Adapted with permission from Peterson C. Canadian Guidelines for

Imaging. 2002 (unpublished)
b Santiago RC, Gimenez CR, McCarthy K. Imaging of osteomyelitis

and musculoskeletal soft tissue infec-tions: current concepts. Rheum Dis

Clin North Am. 2003;29(1):89-109.
c Cardinal E, Bureau NJ, Aubin B, Chhem RK. Role of ultrasound in

musculoskeletal infections. Radiol Clin North Am 2001;39(2):191-201.

30 Bussières et al Journal of Manipulative and Physiological Therapeutics
January 2008
Diagnostic Imaging Upper Extremity Disorders

APPENDIX E. TYPICAL EFFECTIVE IONIZED RADIATION Rivières for their valuable editorial input, and to Drs. Carlo
DOSE FOR COMMON IMAGING PROCEDURES* Ammendolia, DC, PhD, Joe Lemire DC, MSc, John Triano,
DC, PhD, and Jacques Duranceau, MD for providing
Class Typical effective Examples constructive advice. The authors are indebted to those who
dose (mSv) assisted us during all or part of the project, including Drs.
0 0 US, MRI Mark Laudadio, DC, Christian Eid, DC, Julie Roy, DC,
I b1 Radiograph: cervical and thoracic Nicholas Beaudoin, and Mme Valérie Lambert, academic
II spine, extremities, pelvis, and lungs and technology support, Computer system development
III 1-5 Lumbar spine radiograph, NM, division at UQTR. Finally, we would like to thank Mrs.
cervical spine CT Vicki Pennick, RN, BScN, MHSc, Senior Clinical
5-10 Chest and abdomen CT Research Project Manager, Managing Editor, Cochrane
Back Review Group, Institute for Work and Health for her
*Classification of the typical effective dose of ionizing radiation from valuable advice and pertinent comments and suggestions as
a public representative. We further apologize, once again,
common imaging procedures. Adapted from: European Commission. to those who experienced temporary technical difficulties
Radiation Protection 118. Referral guidelines for imaging in conjunction with the evaluation questionnaires at the onset of Website
with the UK Royal College of Radiologists; Italy 2001. p. 21. consultations (Delphi, Public and External review).

APPENDIX F. ADDITIONAL READING RECOMMENDED ON We wish to acknowledge all Delphi panelists who have
MRI dedicated their time to this project. The following is a list of
Delphi panelists who have agreed to be acknowledged for
• Scordilis PJ, Grenier JM, Wessely MA. Shoulder their significant contribution to the research project.
MRI. Part 1: Basic overview. Clin Chiropr 2005;8:93-101.
Allan Adams, DC, MSEd
• Grenier JM, Scordilis PJ, Wessely MA. Shoulder Texas, USA, Texas Chiropractic College (Academic and
MRI. Part 2: Overview of common pathological condi- Researcher)
tions. Clin Chiropr 2005;9:151-60.
Peter Aker, DC, MSc, FCCS, FCCRS
• Wessely MA, Hurtgen-Grace KL, Grenier JM. Elbow Ontario, CANADA (Clinician and Researcher)
MRI. Part 1: Normal imaging appearance of the elbow. Clin
Chiropr 2006;9:198-205. Thomas F. Bergmann, DC
Minnesota, USA, Professor, Northwestern Health Sciences
• Wessely MA, Grenier JM. Elbow MRI. Part 2: The University (Academic, Clinician)
imaging of common disorders affecting the elbow region.
Clin Chiropr 2007;10:43-9. Douglas G. Brandvold, DC
British Columbia, CANADA (Clinician)
• Wessely MA, Grenier JM. MR imaging of the wrist
and hand—A review of the normal imaging appearance Jane Cook, DC, DACBR
with an illustration of common disorders affecting the wrist Bournemouth, UK, Anglo European Chiropractic College
and hand. Clin Chiropr 2007;10(3):156-64. (Academic)

APPENDIX G. ACKNOWLEDGMENTS Jeffrey Cooley, DC, DACBR
Perth, West Australia, Senior Lecturer, Murdoch University
The authors express their sincere appreciation to all (Academic)
Delphi panelists (phase 5), external reviewers (phases 4 and
7), and to the quality of literature assessors (phase 2): Vince DeBono, DC
Jeffrey Cooley, Jonathon Egan, Michael Morgan, Julie Illinois, USA, Dean of Clinics, National University of
O'Shaughnessy, and Jason Napuli, whose significant Health Sciences (Academic, Clinician)
contributions were essential in the completion of this
project. We are grateful to chiropractic college presidents Martin Descarreaux, DC, PhD
for recommending faculty members for the Delphi panel. Quebec, Canada, Université du Québec à Trois-Rivières
We have appreciated the feedback received by colleagues (Researcher, Academic and Clinician)
in the field during and after the worldwide consultation on
the Web (Phase 6). Many thanks to Dr. Andre Cardin of Renee DeVries, DC, DACBR
Université du Québec à Trois-Rivières for his significant Minnesota, USA, Associate Professor and Consulting
input in the initial draft (phase 3), Dr. Michelle Wessely of Radiologist, Northwestern Health Sciences University
the Institut Franco-Europeen de Chiropratique and Dr. (Academic)
Julie-Marthe Grenier of Université du Québec à Trois-

Journal of Manipulative and Physiological Therapeutics Bussières et al 31
Volume 31, Number 1 Diagnostic Imaging Upper Extremity Disorders

Shawn Dill, DC Eric Jackson, DC, FCCRS
California, USA, Professor, Life College Chiropractic West Ontario, Canada (Clinician)
(Academic and Clinician)
Amanda Kimpton, BAppSc(Chiro), PhD
Paul Dougherty, DC, FACO Victoria, Australia, RMIT University (Academic and
New York, USA, New York Chiropractic College Clinician)
(Academic)
Dana J. Lawrence, DC, FICC
Dennis Enix, DC, MBAc Iowa, USA, Associate Professor
Missouri, USA, Associate Professor of Research, Logan Palmer Chiropractic College (Academic and Researcher)
College of Chiropractic (Researcher and Clinician)
Douglas Lawson, BA, DC
Francis Fontaine, DC, MD Alberta, Canada (Researcher and Clinician)
Quebec, Canada, Lecturer, Université du Québec à Trois-
Rivières (Clinician) Kathleen Linaker, DC, DACBR
Georgia, USA, Assistant Professor
Simon Forster, DC, DABCO Director Clinic Radiology, Life University
Texas, USA (Clinician) College of Chiropractic (Academic, Clinician)

Edward Fritsch, DC Tracey Littrell, DC, DACBR
Texas, USA, Texas Chiropractic College (Academic and Iowa, USA, Associate Professor, Diagnosis and Radiology,
Clinician) Palmer-Davenport Chiropractic College (Academic)

Bryan Gatterman, DC, DACBR Stephan Mayer, BSc, DC
California, USA, Life West Chiropractic College California, USA, Chair of Diagnostic Sciences and
(Academic and Clinician) Associate Academic Dean, Cleveland Chiropractic
College (Academic)Ian D. McLean, DC, DACBR
Claude Gauthier, DC
Quebec, Canada (Clinician) Iowa, USA, Professor, Clinical Radiologist Professor,
Director of Clinical Radiology and Chiropractic
Kristin L. Grace, DC, DACBR Residencies, Palmer-Davenport Chiropractic College
Hastings, New Zealand, Senior lecturer (Academic and Clinician)
New Zealand Chriopractic College
(Academic and Clinician) Timothy J. Mick, DC, DACBR, FICC
Minnesota, USA (Clinician)
Gary Greenstein, DC
Connecticut, USA (Clinician) Silvano Mior, DC, FCCS
Ontario, Canada, Canadian Memorial Chiropractic College
Julie-Marthe Grenier, DC, DACBR (Researcher and Clinician)
Quebec, Canada, Université du Québec à Trois-Rivières
(Academic, Research) Tom Molyneux, DipAppSc (H Biology), DipAppSc
(Chiro), BAppSc(Chiro), DACBR, FACCR,
Mitchell Haas, DC, MA GradDipTertEd.
Oregon, USA, Dean of Research, Western States Victoria, Australia, RMIT University (Academic)
Chiropractic College (Academic and Researcher)
William E. Morgan, DC
Michael W. Hall, DC, DABCN Maryland, USA, Adjunct Professor, New York College of
Texas, USA, Associate Professor, Parker College of Chiropractic, National University of Health Sciences
Chiropractic (Academic and Clinician) (Clinician)

Jan Hartvigsen, DC, PhD Elli Morton, DC
Odense, Denmark, Dean of Research, University of British Columbia, Canada (Clinician)
Southern Denmark (Academic and Researcher)
Greg Norton, DC, FACO, FIACN
William Hsu, DC, DACBR Iowa, USA (Clinician)
Ontario, Canada, Associate Professor, Canadian Memorial
Chiropractic College (Academic) Sandra O’Connor, DC, DACBR, FCCR
Ontario, Canada (Clinician)

32 Bussières et al Journal of Manipulative and Physiological Therapeutics
January 2008
Diagnostic Imaging Upper Extremity Disorders

Rosemary Pace, RN, DipAppSc(MedRad), MEd (ICT), Rand Swenson, DC, MD, PhD
MBus, GradDipEd, GradDipBus New Hampshire, USA, Associate Professor of
Victoria, Australia, RMIT University (Academic and Anatomy and of Medicine, Chairman, Department
Researcher) of Anatomy, Dartmouth Medical School
(Academic, Clinician)
Joseph Pfeifer, DC
New York, USA, New York Chiropractic College (Academic) John Sweaney, AM, DC
New South Wales, Australia, Chiropractic Education
John Pikula, DC, FCCR(C), FCCS(C), FCCO(C) Consultant (Clinician)
Ontario, Canada (Clinician)
Cliff Tao, DC, DACBR
Brock Potter, DC California, USA (Clinician)
British Columbia, Canada (Clinician)
Jeffrey Thompson, DC, DACBR
Tania C. Pringle, BPE, BA, DC, DACBR, FCCR(C) Texas, USA (Clinician and Researcher)
Ontario, Canada, Assistant Professor, Canadian
Memorial Chiropractic College (Academic) Jann Thulien, DC, DACBR
Ontario, Canada (Clinician)
Serge Roux, DC, DABCO
Quebec, Canada (Clinician) Michelle A. Wessely, BSc, DC, DACBR
Paris, France, Professor, Head of Radiology and Clinical
Peter Scordilis, DC Research, Institut Franco-Europeen de Chiropratique
New Jersey, USA (Clinician) (Academic and Clinician)

Paul Sherman, DC, Assistant Professor Michael Whitehead, BS, DC, DACBR
Connecticut, USA, University of Bridgeport College of Missouri, USA, Chair of Diagnostic Sciences, Cleveland
Chiropractic (Academic and Clinician) Chiropractic College (Academic and Clinician)

Thomas A. Souza, DC, DACBSP DELPHI PROCESS ADVISORS
California, USA, Dean of Academic Affairs, Palmer
Chiropractic College West (Academic and Clinician) Meridel I Gatterman, MA, DC, MEd,
Colorado, USA, Chiropractic Educational Consultant
John Stites, DC, DACBR
Iowa, USA, Palmer Chiropractic College Peter Miller, BSc, MSc, FCC (Orth)
(Academic) Bournemouth, UK, Anglo-European College of
Chiropractic