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Musculoskeletal clinical case of the month – SPECT

Imaging in Musculoskeletal medicine

Good musculoskeletal patient care starts with a thorough clinical assessment. Sometimes it may be appropriate to request further investigation. Imaging modalities are becoming more readily available for patients to access. On one hand this allows for more in-depth investigation. On the other, as with any aspect of clinical medicine, it is vital the clinician understands the strengths and limitations of the investigation they are requesting.

Ultrasound, MRI and CT scanning are commonly used imaging techniques in healthcare. A newer technique, SPECT, is becoming more available and is providing to be extremely useful clinically. This case study highlights the key points around the use of SPECT scanning.

Single-photon emission computed tomography (SPECT):

Traditional computed tomography (CT) scanning is initially obtained while the patient is lying on a bed that moves into a ring- or ‘donut’-shaped X-ray machine. The X-ray machine rotates over a 360-degree arc around the patient, allowing for images to be reconstructed in three dimensions.

SPECT is a specialised type of bone scan, where images are taken after an injection of a nuclear medicine radiopharmaceutical (e.g. technitium-99m). The injected tracer ‘sticks’ to specific areas in the body where there is higher metabolic activity, and emits gamma rays, which in turn are detected by gamma cameras. The cameras rotate over a 360-degree arc around the patient, allowing for images to be reconstructed in three dimensions.

The increased areas of tracer uptake are then demonstrated as ‘hotspots’, which indicate underlying pathology. The sensitivity for detecting bone disease is high, but the specificity is extremely low (i.e unable to differentiate between pathologies). It is then imperative that the clinical history and background of the patient is carefully correlated to understand the nature of any hotspots.

Clinical Presentation

  • 17 year old male school rugby player
  • Pain developing over base of first metatarsal over past 2 years
  • No previous acute injury to area
  • Pain increased in intensity to eventually caused pain on walking and cessation of all physical activity
  • Patient self presented to A+E where x-rays were taken, with no abnormal findings. Foot and ankle sprain advice given.
  • GP referred to physio who initiated calf strengthening and ankle/foot mobility exercises with only mild improvement in symptoms
  • DH – Nil else
  • PMH – Nil of note
  • FH – Nil of note
  • Patient referred to orthopaedics by GP as not making any real improvement with physio.
  • MRI conducted which showed no significant bone or ligament abnormality. Discharged from orthopaedics.
  • Presented to LBSM 14 months after first onset of pain.
  • Examination at consultation:
  • Anatalgic gait, unable to weight bear without significant pain from midstance to toe off
  • Very tender and stiff over the base of first and second metatarsal and tarsometatarsal joints
  • Deconditioned lower limb on effected side
  • Patient asked to offload in Aircast boot
  • Referred for SPECT scan


  • Top left – X-ray left foot. No bone abnormality detected
  • Top right – MRI left foot. No bone oedema in midfoot, no ligamentous damage (e.g. Lisfranc complex intact)
  • Bottom left and right – SPECT-CT. Hot spot and increased bone activity at 1st and 2nd tarsometarsal junction
Musculoskeletal clinical case of the month Musculoskeletal clinical case of the month - SPECT


Podiatry review;

  • Patient sent for gait analysis, kinematic and force place assessment;
  • Custom made orthotics for daily activity aiming to;
  • protect against tarsometatarsal compression and stress during normal gait
  • improving medial column alignment and stability, optimising 1st ray
  • Further orthotics made for sport specific purposes


  • Gradually weaned out of boot until able to walk around house pain free
  • Midfoot and forefoot mobilisations, actively and passively
  • Generalised lower limb strengthening programme
  • Foot intrinsic and calf strengthening programme
  • Progressive proprioceptive and pylometric rehabilitation
  • Graded return to running, including Anti-gravity treadmill

Patient made a full return to Rugby within 3 months of rehabilitation at LBSM. A repeat scan was not required as patient remained asymptomatic.

Use of SPECT in musculoskeletal and sports medicine

SPECT and radionuclide imaging is already well grounded in musculoskeletal and orthopaedic practice. Examples include the detection of;

  • Malignant disease in the axial skeleton
  • vertebral column and pelvis are the most frequent sites of metastatic bone disease because of their high red marrow content
  • radionuclide imaging may be the only modality to demonstrate pathology before it becomes evident on anatomical imaging
  • Osteomyelitis or other bone infection
  • Joint prosthesis infection and loosening
  • Paget’s disease

In sports medicine, as this case demonstrates, the use of SPECT can be very informative, giving deeper insight to biomechanical loading patterns and stressors that may potential act as injury risk factors. Some examples may include the detection of;

  • Fractures that are absent radiographically, e.g. stress or insufficiency fractures
  • Biomechanical overloading in the skeletal system:
  • pars overload in patients with repeated spine flexion/extension cycles e.g. cricket, tennis players
  • foot and ankle overload, e.g. runners or contact sports
  • Impingement syndromes
  • SPECT has shown to be sensitive to detecting hip impingement when MRI is normal
  • Ankle impingement, posterior and anterior

Practical considerations with SPECT

As with any intervention/investigation, the risks and benefits need to be fully considered and clearly articulated to the patient.

As a radioactive tracer is used, the radiation exposure with SPECT is around 5 mSv, equivalent to approximately 2 years worth of natural background radiation (for comparison, a single x-ray emits 0.1 mSv, equivalent to 10 days natural background radiation). This exposure, however, is limited because the agent typically have short half-lives (technitium-99m half life is 6 hours).

Other risks include an allergic reaction to the tracer or contrast agent. Women who are pregnant or nursing should also not undergo a SPECT scan.

The risks associated with SPECT may be more ethical to take when carrying out medical assessment for potential serious disease, over routine biomechanical assessment. Previous exposure to medical and non-medical radiation must also be considered.

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    Orla Mulligan
    Administration and Social Media Manager
    Administration, LBSM

    Orla Mulligan is the administration and social media manager for LBSM. She has a strong background in sport having herself played netball at an elite standard for the U21s Northern Ireland team in the European Championships as well as the U21s competition for Saracen Mavericks.

    She understands youth sport pathways having herself played and training in the netball Kent regional pathway. She has a keen interest in most sports and a good understanding of how injury and illness can impact on the mind and body, as well as rehabilitation pathways.

    She looks forward to speaking and assisting LBSM patients and gives her best support to them during their treatment pathway.

    A day in the life of Orla involves communicating with patients via phone and email, managing and organising clinics, operations and media management.

    Outside of work, Orla is a gym enthusiast, enjoys tennis and still finds the time for an occasional game of netball.

    Maddie Tait
    BSc, MSc
    Associate, LBSM
    Musculoskeletal and Sports Podiatrist

    Maddie treats and manages complex foot and ankle injuries in London and Surrey.

    She is particularly interested in helping her patients improve their quality of life and achieve their personal goals, working closely with Foot and Ankle Consultants, Sports Medicine Doctors and Physiotherapists.

    Maddie has a sporting background herself having previously represented England in Hockey. She understands the demands of elite sport and the importance of physical and mental health. In her spare time, Maddie continues to enjoy an active lifestyle by running, cycling and attending a Pilates class.

    Having graduated from University of Brighton with a MSc (hons) in Podiatry, Maddie focused her career in Podiatric Sports Injuries and Biomechanics. Previously she completed a BSc (hons) in Sport Science at Loughborough University.

    A day in the life of Maddie involves consulting patients in clinic, performing gait and biomechanical assessments, measuring and fitting orthotics and braces. She also regularly teaches and presents at sports medicine and podiatry conferences.

    Outside of work, Maddie still finds time to play hockey and enjoys running and skiing.

    Mr Prakash Saha
    Consultant Partner, LBSM
    Consultant in Vascular Surgery

    Mr Prakash Saha is a Consultant Vascular Surgeon at LBSM. He takes pride in providing the best possible results for his patients by using the most appropriate non-surgical and surgical methods based on clinical evidence, patient results and satisfaction.

    He treats fit and active people suffering with a range of cardiovascular issues, from painful leg swelling associated with exercise to venous insufficiency, post-thrombotic syndrome and leg ulcers. He also treats people with arterial system problems including poor circulation, compression syndromes and aneurysms. He carries out both endovascular and open aortic repair and has some of the best outcomes in the country.

    Mr Saha studied medicine at the United Medical & Dental Schools at Guy’s and St. Thomas’ Hospitals before completing his higher surgical training in London and the South East. During this time, he was awarded the prestigious NIHR Clinical Lectureship in Vascular Surgery at St. Thomas’ Hospital, giving him comprehensive training in open and endovascular techniques for treating arterial and venous disease. Prakash completed his aortic surgery training at the St. George’s Vascular Institute before carrying out a specialist fellowship at the Royal Prince Alfred Hospital, Sydney.

    Mr Saha regularly lectures and runs workshops across the globe on the latest surgical techniques to treat vascular disease. He has also been awarded a number of research grants from the Royal College of Surgeons, the Circulation Foundation, the Wellcome Trust, the Academy of Medical Sciences, and the British Heart Foundation, which has led to over 80 publications and the development of innovative technologies to help treat patients. For this work, Prakash has received a number of prizes, including the Venous Forum prize from the Vascular Society of Great Britain and Ireland, an International Young Investigator Award, and an Early Career Investigator Award from the American Heart Association.

    A day in the life of Mr Saha involves seeing patients in clinic, operating in surgical theatre or lecturing at his university. He also regularly teaches and presents at vascular and sports medicine conferences.

    Mr Saha is an avid cyclist and tennis player (although yet to get a set of Dr Seth!). Outside of work, he spends time with his family who consists of 3 children and enjoys travelling.

    Dr Gajan Rajeswaran
    Consultant Partner, LBSM
    Consultant in Sports and Musculoskeletal Radiology

    Dr Gajan Rajeswaran is a Consultant Musculoskeletal Radiologist at LBSM, with an extensive background of working in elite sport. He is one of the most recognised radiologists in the sports medicine field. He provides top level imaging and medical diagnostic services for patients and athletes.

    Dr Gajan Rajeswaran completed his undergraduate medical training at Imperial College London and his radiology training at Chelsea & Westminster Hospital. He has obtained two post-CCT fellowships in musculoskeletal imaging. He was appointed as a consultant at Chelsea & Westminster Hospital in 2011.

    He has a passion for all sports having worked as a radiologist at the Glasgow Commonwealth Games and London World Athletic Championships and continues to support The Championships, Wimbledon. He also continues to work with a number of Premier League and Championship Football Clubs, Premier League Rugby Clubs, England Sevens Rugby, British Athletics and the Lawn Tennis Association.

    A day in the life of Dr Rajeswaran involves giving his expert opinion on investigations such as MRI and CT scans, x-rays and ultrasound. He also performs injection lists under ultrasound, CT and X-ray including spinal injections. He also regularly teaches and presents at sports medicine conferences.

    Dr Gajan Rajeswaran is an avid football fan and life-long fan of Tottenham Hotspur (for which he offers no apologies!). Outside of work, he spends time with his family and has a keen passion for photography.

    Dr Ajai Seth
    Medical Director, LBSM
    Consultant in Sport and Exercise Medicine

    Dr Ajai Seth is a Sport and Exercise Medicine Physician. He has dedicated his career to helping people with sport and exercise related injury and illness. He consults and treats everyone from the elite athlete to the weekend warrior.

    Dr Ajai Seth is part of the British Tennis Sports Physician team at the LTA and has also provided cover to elite athletes at Wimbledon Tennis, European Tour Golf, Premier League Football, British Athletics, and the Men’s England Football academies as part of the FA.

    He also prides himself for working in disability sport and is currently the Chief Medical Officer for Team GB Wheelchair Tennis which has taken him to the Olympics and Paralympics.

    Dr Ajai Seth is dedicated to education, training and research and is a Senior Lecturer in Sports Medicine at King’s College London where he lectures in all aspects of Sports Medicine and Science.

    He also has a passion for travel and Expedition Medicine, which has seen him accompany medical, scientific and charity expeditions all around the world. He also has vast experience in treating musculoskeletal injuries from children and adolescents to veteran exercisers, both male and female.

    Dr Seth also has positions in leading Sport Medicine organisations, including the non-executive board for the UK’s largest Sports Medicine charity, BASEM and Past President for the Royal Society of Medicine. 

    A day in the working life of Dr Seth involves consulting his patients in clinic, performing diagnostics and ultrasound guided injections. He also regularly lectures and tutors students and presents at sports medicine conferences internationally. He also spends part of the working week at the National Tennis Centre, LTA, supporting British Tennis players.

    Outside of work, Dr Seth enjoys playing club tennis, triathlon, golf, running and skiing (but will give any sport a go!). He enjoys keeping fit and active and good quality family time with his wife and three children.