Choosing Wisely recommendations guide new ankle and knee imaging campaign

21 Oct 2016
A new program on ankle and knee imaging for Australia’s health professionals - developed in conjunction with musculoskeletal experts and in line with RANZCR, Australian Physiotherapy Association and Australian College of Nursing Choosing Wisely Australia® recommendations and RACGP clinical guidance for MRI referral - has been launched by NPS MedicineWise.
Australian data* suggests that about 20% of all the sprains and strains managed by GPs in Australia in 2011–12 were ankle injuries, and about 5% were knee injuries. Ankle ultrasounds are requested in almost 40% of newly presenting   cases—despite Australian guidelines not recommending ultrasound to investigate ankle sprains.
The new ankle and knee imaging program provides health professionals with an update on the latest imaging recommendations for the type of acute knee and ankle injuries that are commonly seen in general practice. The program includes key factors to consider when deciding whether to refer for imaging—and, when imaging is indicated, guidance on selecting the most appropriate imaging modality.
The program also emphasises the importance of good physical examination skills, which in combination with patient history can be as good as imaging in diagnosing these injuries.
Dr Andrew Boyden, NPS MedicineWise Medical Adviser says that determining whether an investigation is indicated can be challenging in clinical practice, in both balancing the benefits for appropriate investigation with the potential harms, while also managing patient expectations.
“One factor to consider in balancing the risks and benefits of imaging is that the discovery of incidental findings can lead to unnecessary tests or treatments and their associated risks. Notably, incidental meniscal tears seen on MRI are reasonably common in the general adult population, particularly in older people,” he says.
“Patients can benefit through gaining a better understanding that in the case of strains, imaging is often unlikely to make any difference to management or speed of recovery.”
The program provides an update and refresher on physical examination to diagnose acute ankle and knee injuries such as fracture, ACL tear and meniscal injury and lateral ankle sprain and provides resources to assist GPs provide reassurance to patients that imaging is not always required to investigate ankle and knee injuries. The program outlines:
  • Guidelines (Ottawa Rules, RACGP) that promote physical examination and history-taking to identify likely ankle and knee injury
  • Indications and considerations following knee and ankle injury which warrant imaging and the imaging modality to request.
  • Role of conservative management
  • How to talk with patients when they’re expecting/requesting imaging which may not be clinically indicated.
The ankle and knee imaging program includes:
  For more information, go to
*2014 BEACH study: Evaluation of imaging ordering by general practitioners in Australia 2002–03 to 2011–12.

Last reviewed 21 October 2016