Happy New Year!

At the start of each new year, it is healthy to look back on what has transpired in the past year and where we are headed, both personally and professionally. For Sports Health, it’s the start of our fifth year. Our total average circulation for 2012 was almost 22 000, and we have found ourselves with readers across the globe, from Europe to Australia and from South America to the Middle East. Many have found us on the Internet, with over 400 000 visits in 2012. More important, Sports Health is now listed on PubMed Central (http://www.ncbi.nlm.nih.gov/pubmed), which will help us to become the global journal of sports care that we strive to be. To all of those members of the American Orthopaedic Society for Sports Medicine, American Medical Society for Sports Medicine, Sports Physical Therapy Section, and National Athletic Trainers’ Association that helped bring this to fruition, we thank you! To all of those who contributed manuscripts and reviews, we appreciate your expertise, time, and effort! Without your contributions, we could not compete in today’s world of medical publishing. As this publishing world evolves, we will continue to strive to bring the most relevant publications to our readers.

As part of this effort to publish the most current research, this issue of Sports Health features 3 reviews on magnetic resonance (MR) imaging. These techniques are now available for the care of athletes and patients in general. For a look at how technology has changed the practice of orthopaedic medicine, look no further than these technologies.

Not that long ago, while I was an orthopaedic resident, the only imaging routinely available was x-ray, and those techniques were a lot different from what we enjoy today. There were no c-arms in the operating room for fixing fractured hips or for nailing long bone fractures. We were able to image bone well, but soft tissue was best investigated under physical examination. In addition, we could not image the cruciates or the menisci of the knee, the labrum of the shoulder or hip, or an elbow defect without injecting dye into the joint and examining the shadows on arthrograms. Most clinicians relied heavily on physical examination. That era presented a tremendous opportunity to learn from great clinicians who over time had fine-tuned their physical examination skills. My own chief during residency, Dr William Smith, was a master of this art and took tremendous pride in developing a differential diagnosis and then working through the examination to pinpoint the problem. There were no computers or electronic medical records back then. There was a lot more patient contact—talking, listening, and examining. Unfortunately, at that time, the true soft tissue pathology was often not confirmed until an arthrotomy was performed in the operating room.

As the 1980s evolved, arthroscopy changed much of patient care in the sports world. Clinical impressions could be confirmed with diagnostic arthroscopy before the definitive procedures were performed—a big step forward for patient care. By the late 1980s, MR was making its mark, as it detailed the makeup of the intra-articular structures that we struggled to examine but could not visually inspect. When used appropriately, MR has lessened the need for diagnostic arthroscopy, advancing patient care by avoiding unnecessary trips to the operating room and bouts of anesthetics.

Fast forward to 2013 where imaging, especially MR, is so far advanced that for some practitioners it has nearly replaced the physical examination. In this transition, the fear is that some have lost the ability to tie the symptoms and signs to reach a diagnosis, choosing rather to rely on the features of imaging. Personally, it’s not unusual to see patients in the clinic with MR images in hand requesting an operation for pathology documented on an MR and who have never undergone a physical examination for the problem, which is sad because this is not good patient care. It’s no secret that imaging technologies can be very sensitive and detect many “abnormalities” that are not symptomatic or in need of treatment of any sort. Furthermore, the sensitivity, specificity, and accuracy are dependent on the training and specialization of those interpreting the studies.¹ It is no doubt that the surgical indications increase if imaging is used in isolation as the sole determinant of the diagnosis. The value added by an examination performed by a senior clinician was clearly demonstrated by Hardy et al¹ and previously published in Sports Health. The clinical importance of this should not be underestimated in today’s technological world. Also, there are clinical presentations, such as a locked knee, that obviate the need for preoperative imaging, and experienced clinicians can recognize and surgically address these presentations without the added cost of imaging.

The trend of increasing dependence on imaging and lessening the role of history and physical examination is dangerous for clinical medicine. Now don’t get me wrong: I think we should use imaging technologies to their fullest advantage, just not to the exclusion of the history and physical examination. The best clinical care features all 3 (history, physical examination, and imaging) to arrive at the diagnosis. Some might question this rationale and argue that all we need are the images of the involved structures. However, those trained in musculoskeletal medicine know that MR cannot determine anterior tibial translation or a pivot shift at the knee; range of motion or pain in provocative positions at the hip, shoulder, or elbow; and many other features that the physical examination allows. The discrimination between joint laxity and instability, for instance, is never easy and requires a fine-tuned physical examination often of both extremities for comparison. Astute clinicians will utilize all information obtainable to guide the care of their patients.

Focusing on the best care for our patients is clearly needed in today’s society. With all of the attention that the politics of medicine has received recently, it’s most important for clinicians to decide what is best for the patient. So as we begin this new year, one that will certainly see profound changes in the American health care system, clinicians can lead the way to improved patient care by wisely and efficiently using all of their skills and technologies available.

—Edward M. Wojtys, MD
Editor-in-Chief