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Lecture Hall Diabetic Foot | Analysis

Diagnostic Imaging: Radiographic Interpretation


Robert Christman
Robert Christman, DPM, FACPR
Director of Radiology & Associate Professor
Temple University School of Podiatric Medicine
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Lecture Transcription




Presentation

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Welcome! My name is Dr. Christman. This presentation, Radiographic Interpretation, is interactive. It may seem at first glance to be introductory, but it is not. You will find it to be challenging, and it will test your skills.

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I will use a different educational approach that will require active learner participation. Numerous examples of radiographic pathology will be demonstrated; however, the emphasis will be on appropriate description of radiographic findings as opposed to merely recognizing the diagnoses of classic pictures.

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Initial training in podiatric radiology typically does not emphasize the description and recording of abnormal radiographic findings. Most training earlier on emphasizes the recognition of classic radiographic pictures of all the common pathologies that might be seen in the foot and the ankle. Many podiatrists in my experience lack confidence in using appropriate terminology to describe abnormal findings, and this will be the emphasis of this presentation.

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Payment for the radiographic studies that you perform is for the description of findings, not the diagnosis. Insurance companies will perform random audits of charts. A radiologist will review not only the radiographic quality, but they will review the report of findings. If this is found to be unsatisfactory, you will be placed on a probation period. If after this period of time, the report is still unsatisfactory, there will be no further reimbursement from this insurance company. This will obviously delay the diagnosis and treatment of your patients since you will have to send them out to another imaging center for the radiographic study which is not only an inconvenience to the patient but will have an impact on the economy of your practice since you will not gain the payment from these particular studies.

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Be objective when you report your radiographic findings, simply state what you see, reserve the diagnoses and the etiologies for your assessment. My challenge to you is to not include a diagnostic term in your description of findings. Now, this report ideally should be provided separately. It appears more professional, especially if another physician asks for a copy of your x-ray report. At a minimum, however, create a separate paragraph within your SOAP note in the objective section prior to your assessment.

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Most radiographic studies of the foot and ankle are performed solely to assess bone pathology. Now, bone has 4 primary radiographic attributes. They include position, form, density, and architecture. Abnormalities of bone therefore can be described as abnormalities of position, form, density, and architecture. Now let us look at each of these individually and see the terminology that is used.

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The position of one bone’s axis relative to another bone may be abnormal. If this is the case, one simply needs to note that the angle between the 2 bones is either increased or decreased. Another positional abnormality regards the apposition between articulating bones, for example, 2 bones at a joint should appose one another 100%. If not, then there is less than 100% apposition. It may be partial apposition, which is subluxation the diagnosis or 0% apposition between 2 bones would be dislocation. If there is less than 100% apposition, then you should also describe direction of displacement and/or angulation of the distal segment relative to the proximal segment.

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Each and every bone in the foot and ankle has a characteristic form. Form refers to its shape, size, girth, length, and contour. Everyday terms generally are used to describe abnormal form, for example, abnormalities in shape may describe something to be rectangular, circular, or oval shaped. In reference to size, it may be large or small. The girth of the bone may be increased or decreased. In reference to the length, it may be shorter or longer. The contour as opposed to being smooth, it may be wavy, undulating, etc.

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Each bone has characteristic increased and decreased densities. This is probably one of the simplest abnormalities to record, because one can simply state that there is an abnormal increased density or abnormal decreased density. Now, I am sure you are familiar with multiple other terminologies that are used to describe increased and decreased densities, for example, synonyms for increased density include radioopaque, sclerosis, and eburnation, which is subchondral sclerosis. Synonyms for decreased density include radiolucent, rarefaction, and osteopenia. When describing an increased density or decreased density, one should use an appropriate figurative adjective prior to that phrase; for example, one might see a geographic increased density. It might be a solid increased density and ill-defined increased density. One may see a spotty decreased density.

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Lastly is the bone’s architecture. Each bone has a margin along its external surface. This margin should be well defined and continuous. If not, terminology to describe abnormalities may simply be ill-defined margin, discontinuous margin, or there may be an erosion or defect. There may be a periosteal reaction; and if so, one should describe the picture of this periosteal reaction; is it solid, is it lamellated, etc. Internal architecture primarily involves the cortices and the trabeculations. Abnormalities of the cortex may include cortical thinning or thickening or tunneling of the cortex. When trabeculae are abnormal, typically the finding is resorption of secondary trabeculae, which results in prominent primary trabeculations.

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Now for the good stuff, this is how it works. I will first present a case or radiograph. I will then ask you to find the abnormal findings. There will be a 5-second silence. In that period of time, if you think you will need more time to describe your abnormal findings or to write them down if you wish, then simply click the pause button.

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The first case is an 11-year-old male who presents with a painful heel. I would like you to describe the appearance of the calcaneal apophysis and the adjacent metaphysis. After doing that, decide whether or not these findings are normal or abnormal.

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The calcaneal apophysis is increased in density or sclerotic relative to the calcaneal body. This is a normal finding. Additionally if apophysis appears to be divided into multiple segments, this also is a variation of normal ossification. Some people refer to this picture as “fragmentation.” I prefer not to use this term since it can infer abnormality. The jagged, irregular appearance to the metaphysis also is a normal variant finding. By the way, the term apophysitis is a clinical diagnosis, not radiographic. Furthermore, the term _____ disease is also now known to be normal. In fact what _____ described many decades ago are the 3 findings noted above.

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Variations of the developing bones are often misinterpreted in the pediatric patients, for example, in the mortise ankle view, the black arrow points to an irregular, jagged metaphysis similar to that seen in the previous example with the calcaneal apophysis. The white arrow points to widening of the distal fibular physis laterally which is commonly misinterpreted as fracture in patients who have a history of ankle injury. The irregular proximal ends of lesser metatarsal bones are often misinterpreted as abnormality in patients who have diffuse or vague foot pain or have abnormal gait.

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Our next case is a 62-year-old female who presents with a painful bump along the dorsum of her mid foot. DP and lateral views were obtained. The white arrow points to the area of concern clinically, describe the abnormal findings. Additionally, however, determine which joint the white arrow points to and correlate that to the DP view and note those findings as well.

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These white and black arrows point to spurs along the superior and medial margins of the second metatarsal-cuneiform joint. Spurs when found at the margins of a joint are best referred to as osteophytes. The term osteophyte is the primary feature of osteoarthritis. Associated findings secondarily seen with osteoarthritis include uneven joint space narrowing and subchondral sclerosis or eburnation, which are best demonstrated in the dorsoplantar view.

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This 40-year-old female experiences dull, aching pain in the ankle and tarsal regions. Aside from the calcaneal spur in the ossicle posterior to the posterior talocalcaneal joint, describe the abnormal finding.

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The white arrow points to an extension of the anterior calcaneal process, referred to as the anteater calcaneus. To the left is a gross specimen example demonstrating this extended anterior process. Look at the normal for comparison. The anterior process, though it is slightly elevated, does not extend as far anterosuperiorly as it does above and the above example also appears to articulate with the navicular bone. This is another example demonstrating the anteater calcaneus.

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If the finding anteater calcaneus is demonstrated in a lateral view, then one should order the medial oblique view for clear visualization. On the left, is an example of a bony calcaneonavicular coalition, and on the right a fibrocartilaginous CN bar. Notice that the “articulation” between the anterior calcaneus and the navicular bone on the right appears as an osteoarthritic joint with irregular joint space narrowing, sclerosis at the margins, and spurring.

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Skeletal dysplasias provide great examples of abnormal findings. Name the two primary generalized findings that are seen in these DP and lateral radiographs.

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The 2 generalized findings demonstrated in this patient with osteogenesis imperfecta are thin or gracile tubular bones and generalized osteopenia which is demonstrated by the coarse, prominent primary trabeculations. Other findings that you may have noticed are absence of the first metatarsal head medial eminence from a previous bunionectomy and an exostosis along the medial aspect of the third metatarsal, distal diametaphysis from a previous osteotomy.

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Another skeletal dysplasia is demonstrated with this medial oblique foot view. Describe the abnormal findings.

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This dysplasia, known as osteopoikilosis, demonstrates the following characteristic features: Multiple islands of cortical bone density in periarticular areas or you could simply say there are multiple circular or geographic increased densities adjacent to the multiple joints.

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This 52-year-old male presents with arch pain clinically. Does anything in this lateral view appear unusual? Describe the finding.

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The arrows identify a joint that separates the medial cuneiform into dorsal and plantar segments. The bipartite medial cuneiform, though an uncommon normal variant, in my experience has been associated 50% of the time with arch pain. I have found that injecting cortisone into this joint has relieved symptomatologies in every case.

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This 72-year-old woman presented with a painful bunion. List the abnormal findings.

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You may have missed the abnormality in the soft tissues, because we have been concentrating on bone abnormalities. However, the pertinent finding in this particular case is the geographic air-like density in the soft tissues medial to the first metatarsal head. This, more than likely, was caused by a gas-forming bacteria and the radiographic diagnosis for this finding is soft tissue emphysema.

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Unfortunately, because the initial finding was not recognized at the patient’s first visit, the patient returned 2 months later with this radiograph. The findings include absence of that air-like density, increased soft tissue density and volume adjacent to the joint, and the arrow identifies an ill-defined erosion along the anterior aspect of the first metatarsal head. These findings are now consistent with a septic arthritis and underlying osteomyelitis of the first metatarsal head. Fortunately, this process was very nonaggressive and the patient was able to be treated conservatively.

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Back to the original radiograph, the additional findings that you may have noted included increased intermetatarsal and hallux abductus angles, a prominent first metatarsal head medial eminence, a tibial sesamoid position of No. 7 and partial apposition of the hallux proximal phalanx base with the adjacent first metatarsal head. This apposition is approximately 67%, and the hallux is displaced laterally. These findings are consistent with the following diagnoses: Hallux abductovalgus and bunion deformity with subluxation of the first metatarsophalangeal joint.

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This is an another example of a patient with a painful bunion. There was increased soft tissue density and volume adjacent to the first metatarsophalangeal joint but no air-like densities. The decreased densities seen in the soft tissues throughout this film are actually dirt artifacts. In the second film taken approximately 2 weeks later, there is now gross osteolysis of the first metatarsal head and the hallux proximal phalanx base medially. These findings are consistent with an extremely aggressive infectious process.

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This 45-year-old male presents with a painful ankle secondary to a recent sprain. Describe the tibial lesion, which was an incidental finding.

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The characteristic description of this particular finding is described as serpiginous calcification in a diametaphyseal location. These findings are classic for bone infarct. Bone infarcts are asymptomatic. What you see here is an old healed osteonecrosis. These findings can be associated with patients with alcoholism, pancreatitis, and patients who have recently had hip implants with methylmethacrylate cement.

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This is an example of an alcoholic patient that was radiographed for another concern. Incidental findings include serpiginous calcifications in the first metatarsal shaft and the calcaneus has identified by the arrows.

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This lateral was obtained on a patient who complained of heel pain. The duration was approximately 8 weeks. There was no history of direct injury. Describe the abnormal finding.

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The arrows identify ill-defined, somewhat geographic, increased density in the calcaneal body. Cancellous bone stress fracture in contrast to cortical bone stress fracture may take at least 4 to 6 weeks before first seen in radiographs. Earlier diagnosis can be made with bone scintigraphy or MRI in the proper clinical setting.

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This is one of my favorites. This 32-year-old woman presented with arch pain. Radiographs were obtained and to the right is the DP view. Describe the findings and would you characterize these findings as aggressive or slow growing.

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Several findings to describe here. The cortex is “expanded” or you can say that the cortex is thin. Some people call this a shell periosteal reaction or endosteal thinning, and it involves the proximal two-thirds of the first metatarsal bone. The cortex itself and what is remaining is not broken and there is a geographic decreased

density that contains fine delicate trabeculations that some people may call soap bubbles. All of these findings described indicate a slow growth process, which usually is associated with a benign lesion such as giant cell tumor of bone.

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This is another example of a giant cell tumor of bone involving the talus. Again, it is geographic. The arrow points to its anterior margin in the lateral view. There are multiple trabeculations throughout the lesion and the margins of the lesion though thin are still continuous and intact.

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Yet another skeletal dysplasia. Describe the abnormal findings.

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Multiple exostoses are seen at the following locations: Along the lateral aspect of the fourth toe proximal phalanx, metaphysis, along the medial aspect of the first metatarsal distal diametaphysis, and the medial distal metaphysis of the fifth metatarsal. Individually, these are called osteochondromas. When they are seen in the multiple locations in the skeleton, it is the dysplasia known as the multiple osteochondromatosis and it may result in early closure of the epiphysis resulting in shortening of that particular tubular bone.

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This is the same patient showing numerous exostoses of the distal tibia and fibula and the distal femur

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Let us examine some instances of joint disease. In this case, a 45-year-old female presented with vague aches and pains in both feet. Describe the abnormal findings demonstrated at all the metatarsophalangeal joints.

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The yellow arrows identify erosions along the medial aspects of all lesser metatarsophalangeal joints and the anteromedial aspects of the first metatarsal head. There also is joint space narrowing at all affected joints. Multiple geographic decreased densities are identified by the white arrows in the phalangeal bases and the first metatarsal head. In rheumatoid arthritis, these lesions are known as pseudocysts. Note that there is no lesser toe interphalangeal joint involvement. Characteristically, rheumatoid arthritis does not target the lesser toe IPJs. Also, you may have noticed that there is partial to no apposition between the third and fourth toe proximal phalanges and the respective metatarsal heads. It is unlikely there are at least subluxation or dislocations of these 2 joints. A secondary finding is fibular deviation, which is associated with rheumatoid arthritis.

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This radiograph demonstrates that the finding of fibular deviation of the toes should not be considered a primary feature of rheumatoid arthritis. In this atypical example, you will notice that there is gross tibial deviation of the digits.

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In this case, a 57-year-old female presented clinically with vague aches and pains in both feet. Radiographs were obtained of both feet and this was the only positive finding noted to the right. Describe the abnormal findings demonstrated at the fifth metatarsophalangeal joint.

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Erosions are seen along the medial and lateral aspects of the fifth metatarsal head. In this oblique view, there also is erosion involving the central aspect of the proximal phalanx base. In rheumatoid arthritis as seen above, erosions typically are seen medial only. However, at the fifth metatarsophalangeal joint, it is characteristic to see erosions both medially and laterally. This particular patient did not have findings at any other joints yet, but fifth metatarsophalangeal joint involvement in my experience is commonly an early starting point or target joint for rheumatoid arthritis. These findings have been called figuratively pencil-in-cup, whittling, sucked candy, mortar-in-pestle. These terms refer to a condition known as arthritis mutilans. The differential diagnosis for arthritis mutilans when at the fifth MPJ only is rheumatoid arthritis, but when involving any other forefoot joints including the fifth MPJ, psoriatic arthritis and neuropathic osteoarthritis should be included in the differential diagnosis. The arrows point to indentations along the medial and lateral aspects of the fourth metatarsal head. If you were to look at an anatomical specimen of the fourth metatarsal or any lesser metatarsal for that matter, you will note that these indentations are normal findings that separate the articular surface from the adjacent epicondyles.

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This is a lateral view radiograph of a 15-year-old male with heel pain. Describe the abnormal radiographic findings.

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The obvious finding is the spur at the calcaneal medial tuberosity enthesis. The diagnosis for this would be simply enthesopathy. However, what is of importance here is the suggestion of new bone production along the superior aspect of the spur as identified by the black arrow. Additionally, the inferior surface of the medial tuberosity is very ill defined and there is a suggestion of an erosion at this location. Enthesopathy would include any abnormality at an enthesis, whether it be erosion or spur formation.

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Now you may be wondering why does a 15-year-old male has such obvious spur formation and we thought the same thing, so additional films were obtained of both feet and the dorsoplantar views are shown here. The patient did not have any other history or presentation of symptoms of any other forefoot joint, but describe the additional findings seen at the metatarsophalangeal joints.

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You were right if you identified erosions that were along the medial aspects of the right foot first though fourth metatarsal heads and along the medial and lateral aspects of the left foot fourth and fifth metatarsal heads. Now these findings, though they are bilateral like we saw in the rheumatoid arthritis patient, were asymmetrical in distribution. Additionally, rheumatoid arthritis would not present with lateral erosions at any metatarsal head except for the fifth metatarsal. There is even joint space narrowing at all affected joints, but another important finding as shown by the yellow arrow is a subtle increased density involving the majority of the fourth toe proximal phalanx. Erosions associated with adjacent new bone formation are very unusual to rare to be seen associated with rheumatoid arthritis but, is highly associated with seronegative joint disease. After further workup, this patient was determined to have ankylosing spondylitis.

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Early erosion or pre-erosion does not present with the obvious C-shaped appearance that we have seen so far. In fact, what we see identified by the yellow arrows, has been coined a dot-dash or skip pattern. Look at the second metatarsal head medial aspect. There is a thin white line over the subchondral bone plate, which is continuous and well defined throughout its entirety. The yellow arrows show absence of this thin white line and these are pre-erosive findings in inflammatory joint disease.

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As noted in the patient with ankylosing spondylitis, the presence of new bone formation associated with an erosion is rare with rheumatoid arthritis. However, it is possible to be seen in the seronegative arthritis including psoriatic arthritis, ankylosing spondylitis, and Reiter syndrome. The example to the right shows Martel's sign, which he described as an overhanging margin. Keep in mind however that the overhanging margin of bone is not seen all instances of gouty arthritis. However, when it is present, it is fairly characteristic of the disorder.

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This diabetic patient presented with a swollen foot clinically. Now, I am sure you all know the diagnosis from this picture. However, the challenge I now pose is for you to describe the radiographic findings.

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The pertinent finding in this particular case is subchondral bone resorption as identified by the black arrows. These findings are the primary features of neuropathic osteoarthropathy or Charcot joint. Associated findings in this case include diffuse periarticular sclerosis, partial apposition at multiple metatarsal-tarsal joints, and fragmentation or ill-defined ossicles as identified by the white arrows.

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This 24-year-old male patient presented with chronic aching pain in the ankle and tarsal regions. He identified a history of multiple ankle sprains in the past. What are the abnormal findings?

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First, I would like to identify some normal radiographic anatomies. The sustentaculum tali identified by the black arrow is normally separate from the talar posteromedial process as identified by the white arrow in the lateral view. There should be a fairly wide space separating the sustentaculum from the posteromedial process as identified by the yellow arrow. In patients with medial talocalcaneal coalition, they will have what has been coined the C sign. What the C sign refers to is union between the sustentaculum and the talar posteromedial process. If you look at the yellow arrow, you will notice that there is no separation between these two anatomical landmarks, that they are continuous as one.

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In my experience, the fibrocartilaginous middle talocalcaneal joint coalition is more common than the synostosis. The C sign will still be visible in the lateral view; however, there will be what appears to be an articulation between sustentaculum tali and the talar posteromedial process as identified by the arrowhead. In the calcaneal axial view, the middle talocalcaneal joint instead of being parallel to the posterior talocalcaneal joint, is now angulated at approximately 45 degrees.

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I am fortunate enough to own a gross specimen demonstrating what I believe is a fibrocartilaginous middle talocalcaneal coalition. You will see that the adjacent margins of the talus and calcaneus are very hypertrophied and prominent, which would correlate to the arthritic leg spurring that appears as a joint between the sustentaculum and the posteromedial talar process.

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Other findings associated with tarsal coalition and in particular middle talocalcaneal joint coalition in the lateral view include: Talar head deformity superiorly, which is an osteophyte due to the limited range of motion, which some people refer to as the figurative talar beak and also a flattened or rounded lateral talar process as identified by the black arrow. The black arrowheads identify the synostosis between the sustentaculum tali and the medial posteromedial talar process forming the C sign.

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A 73-year-old male presented with pain at the second metatarsophalangeal joint of 3 weeks’ duration. Describe the abnormal finding at this joint.

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The black arrow identifies an ill-defined, transverse increased density in the second metatarsal head. This is another example of a cancellous bone stress fracture. You may recall the previous example involving the calcaneus. Here is another example in the same metatarsal. Notice how the timeframe is from 3 to 4 weeks before this subtle finding is identified. The importance here is again to contrast this to the more common cortical bone stress fracture or a periosteal reaction may present anywhere from 10 to 14 days.

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The osteochondrosis Freiberg’s disease is defined as osteonecrosis of an epiphysis. It is also known as epiphyseal osteonecrosis. The yellow arrow identifies an ill-defined, cloud-like increased density in the fourth metatarsal distal epiphysis that is mixed with spotty decreased densities. You may also notice a crescent-shaped decreased density that parallels the articular surface. There also is deformity of the epiphysis with some flattening.

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This infant presented with a gross unilateral foot deformity. These are the DP and lateral views of this particular foot. Describe the abnormal findings.

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The findings in this example are purely abnormalities of position. The talocalcaneal angles are decreased in both the DP and lateral views, that is the talus and calcaneus are nearly parallel to one another making them nearly 0 degrees. Additionally, the talus first metatarsal angles are increased in both the DP and lateral views. These are classic features of club foot or talipes equinovarus.

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In summary, attempt to approach a radiographic study in the same fashion you approach a patient. Objectively examine each and every view. Recognize abnormalities. Describe the abnormal findings using appropriate terminology, not the diagnosis. Then consider differential diagnoses and etiologies based upon those findings and correlate them to your clinical findings.

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This meticulously designed lesson by Robert Christman, DPM, Director of Radiology at the Temple University School of Podiatric Medicine, teaches x-ray evaluation and interpretation by example. By the end of this presentation, the participant will be able to: (1) Identify subtle radiographic abnormalities that will allow early diagnosis of disease. (2) Use appropriate terminology to describe specific radiographic lesions, including infection, dysplasia, arthritis, tumor, osteonecrosis, anomaly, and metabolic/endocrine disorders. (3) List differential diagnoses for specific radiographic abnormalities. (4) Distinguish between diseases that appear similarly radiographically.
Goals and Objectives
After participating in this activity, the viewer should be better able to:

1. Identify subtle radiographic abnormalities that will allow early diagnosis of disease.
2. Use appropriate terminology to describe specific radiographic lesions

Estimated time to complete this activity is 50 minutes.
Target Audience
Physicians, diabetes educators, and other health care professionals who treat patients with diabetes.
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Diagnostic Imaging: Radiographic Interpretation
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Diagnostic Imaging: Radiographic Interpretation
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Diagnostic Imaging: Radiographic Interpretation
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It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.
Robert Christman, DPM, FACPR has nothing to disclose.
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Cookies are a technology we use to keep track of users as they move through our Web sites. Your browser allows us to place some information on your computer's hard drive that is associated with the computer you are using. We use cookies to personalize our Web sites and to track your usage across all of our Web sites. Your Web browser can be set to allow you to control whether you will accept cookies, reject cookies, or to notify you each time a cookie is sent to you. If your browser is set to reject cookies, Web sites that are cookie-enabled will not recognize you when you return to the Web site, and some Web site functionality may be lost. The Help section of your browser will tell you how to prevent your browser from accepting cookies.

Although cookies do not normally contain personally identifiable information, if you are a registered user, we may elect to associate your registration information with cookies our Web site places on your computer's hard drive. Associating a cookie with your registration data allows us to offer increased personalization and functionality. For example, you can elect to have our Web sites "remember" your user name and password and bypass the sign-in process on each visit to the site. Without cookies, this functionality would not be possible. Some of our business partners may use cookies on our site (for example, advertisers.) We have told them that we do not want them to use cookie information to track our users' activities once they leave our Web sites. However, because of the way advertisements are served on our Web sites, we do not have total control over how advertisers use cookies on our Web site. If you believe that one of our advertisers is placing an unwanted cookie on your hard drive, please contact privacy officer ( privacy@presentdiabetes.com ) to assist us in resolving the problem.

Uses We Make of Information

In this section of our Privacy Policy, we identify the ways we may use information about you that we have collected.

Aggregate Data

We collect data about visitors to our Web sites for product development and improvement activities. We also use it for market analysis. We may provide information from our Web sites in aggregate form, with identifying information removed, to third parties. For example, we may tell a health care partner what percentage of our registered users are of a particular medical specialty or have certain credentials. Any third party that receives our data must agree not to attempt to re-identify the people it belongs to. For example, we may provide information to a potential advertiser of a product that would appeal to a diabetes patient about what percentage of our users have diabetes. Depending on our agreement with the third parties, we may or may not charge for this information.

Marketing and Advertising

We may target our advertising or marketing depending on information we have about you. For example, a user that is a healthcare professional who treats diabetes may receive advertising for new diabetes therapies (although in neither case will the advertiser have access to any individually identifiable information about you). We may also personalize our Web site based on your interests. For example, you may see different articles in different places on our Web site based on information you have shared with us, or information we have gained by observing your previous behavior, or information we may have gained from your interactions with a third party that shares information with us. We use information for our own internal marketing, research, and related purposes. Third Parties In addition to aggregate information (discussed previously), we may share some kinds of personally identifiable information with third parties as described below.

Other Companies: We have strategic relationships with other companies who offer products and services on our Web sites. When you are interacting with those companies, different rules and privacy policies may apply. We do not control the collection or use of information you provide to these companies, but we do require that those companies clearly state their policies so you can decide whether to give them any information.

Our Employees and Consultants: We contract with other companies and individuals to help us provide services. For example, we may host some of our Web sites on another company's computers, hire technical consultants to maintain our Web-based tools, or work with companies to remove repetitive information from customer lists, analyze data, provide marketing assistance, and provide customer service. In addition, if you are a healthcare professional, we may validate your licensure status and other information against available databases that list licensed health care professionals. In order to perform their jobs, these other companies may have limited access to some of the personal information we maintain about our users. We require all such companies to comply with the terms of our Privacy Policy, to limit their access to any personal information to the minimum necessary to perform their obligations, and not to use the information they may access for purposes other than fulfilling their responsibilities to us. We use our best efforts to limit the use of other companies in areas where personally identifiable information may be involved.

Promotional Offers: Sometimes we send offers to selected groups of customers on behalf of other businesses. When we do this, we do not give that business your name and address. We provide a variety of mechanisms for you to tell us you do not want to receive such promotional offers. For example, we may provide an opt-in box for consumers to receive an email from another business, and we make clear that by opting in you are submitting your data to a third party.

Protection of Information

In this section of our Privacy Policy, we discuss the security measures we take to protect information that we have collected about you.

We have implemented technology and security policies, rules and other measures to protect the personal data that we have under our control from unauthorized access, improper use, alteration, unlawful or accidental destruction, and accidental loss. We also protect your information by requiring that all our employees and others who have access to or are associated with the processing of your data respect your confidentiality. We use security methods to determine the identity of its registered users, so that appropriate rights and restrictions can be enforced for that user. Reliable verification of user identity is called authentication. We use both passwords and usernames, as well as double opt-n verification, to authenticate users. Users are responsible for maintaining their own passwords.

Access to Information and Choices

In this section of our Privacy Policy, we tell you how to obtain and correct information we have about you, and how to choose what types of information you may share with us.

Correction of Information We Have About You

If you believe that registration information collected by our Web site(s) is in error, you may edit your personal profile any time that you like. You can directly edit most of your user profile on the Web site on which you initially registered. Information that you can not edit may only be changed by contacting Web Customer Support (see CONTACTS). Requests for deletion of your record may result in your removal from the registry, but we may keep certain demographic information about you for product improvement purposes. You may contact Web Customer Support and ask for the changes that you would like to make.

Our Employees

Our employees are required to keep customer information private, as a condition of their employment with the company. Only selected, authorized employees are permitted to access personal information. Our employees with access to personally identifiable information are required to attend a confidentiality/privacy training class, and to sign a confidentiality agreement. All employees and contractors must abide by our Privacy Policy, and those who violate that policy are subject to disciplinary action, up to and including termination of their employment and legal action.
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