One of the fun parts of being a podiatrist is the interprofessional interaction we have with the rest of the medical community. Whether it’s receiving consultations from primary care physicians, discussing limb salvage with vascular surgeons or orthopedists, podiatrists are commonly exposed to many professionals. For example, I have a fabulous interventional cardiologist who has done wonders for many of my patients with peripheral arterial disease and critical limb ischemia.

One of the places I’ve noticed some issues, though, is with radiologists. I’m not certain how it is with the rest of the medical community, but in my experience, a large number of radiologists have demonstrated a lack of detail and diagnostic ability when it comes to the foot and ankle, and this concerns me.

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Usually, it takes a radiologist specially trained in musculoskeletal imaging to adequately read a foot or ankle study.

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Take, for example, the radiograph of a recent patient of mine hospitalized for a lower extremity infection. Without boring you with the details, this patient also had a cystic bone tumor in the proximal phalanx of the fourth toe that was most likely an enchondroma. Now, this was a completely ancillary finding, but the radiograph was read as normal with no mention of the bone tumor. The radiologist should at least have made a comment about it, and I assume this finding was missed.

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In a general hospital or clinic setting, the comparatively rare and specialized foot and ankle pathology may just not be seen often enough for radiologists to maintain their expertise in this area.

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I’m certain it’s also highly common for podiatrists to read useless radiology reports of foot radiographs – useless because we often look for mechanical relationships rather than fractures, and radiologists don’t receive this type of training. I’m often surprised when I see a radiograph of hallux valgus with the first intermetatarsal angle marked out! I’d probably pass out if I read a report of a flatfoot radiograph and the radiologist commented on the planal dominance.

How about this one as a second, less obvious, example? The patient with the foot in Figure 2 was thought by the radiologist to possibly have Charcot arthropathy. Now, it is possible this patient had acute Charcot rather than osteomyelitis (subchondral resorption is seen in both diseases), but given the complete lack of fracture, subluxation, or dislocation, plus the history of long-standing ulcerations (visible on the radiographs), Charcot was a highly unlikely diagnosis. Just as a note, the white coloration in the central aspect of the heel ulcer is the visible and palpable medial wall of the calcaneal tuberosity. A little beyond probe to bone!

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All too often, radiologists are asked to render a diagnosis without the important benefit of patient history and physical findings. Reading the MRI, CAT scans and X-rays alone provides only enough information to describe the findings, but often not enough to make the best diagnosis.

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Why Radiologists Make Lower Extremity Interpretation Errors

Our case in Figure 2 sets us up to understand some of the reasons why these errors may occur. It would be too simplistic and generalizing to say, “All radiologists are incompetent when it comes to the foot and ankle.” Instead, let’s think of this with a little more nuance.

Recommendations

I suggest the following actions by all clinicians to improve outcomes in this matter and decrease errors.

Finding a missed tumor or fracture or interpreting an incorrect diagnosis should be something from the past. Radiologists are a valued and important part of the interprofessional medical team, and we have to do everything we can to support their correct imaging reads.