Can Scoliosis Be Misdiagnosed? What an Imaging-Credentialed Scoliosis Clinician in Charlotte Sees on Second Review

By Dr. Justin Dick, DC · Clear Life Scoliosis and Chiropractic Center, Charlotte, NC · Published October 14, 2026

Yes. Scoliosis is misdiagnosed in both directions, and most of the errors I see in Charlotte come from three places: a screening finding treated as a diagnosis, a Cobb angle change that sits inside the measurement error of the method, and a curve labeled idiopathic before anyone asked whether something else was driving it.

I am Dr. Justin Dick, the treating clinician at Clear Life Scoliosis and Chiropractic Center in Charlotte, NC. Before chiropractic I trained in imaging, and I still hold CNMT and ARRT(N)(CT) credentials. That background shapes how I read a referral film. I want to know how the image was taken before I trust what it shows. This post is for parents who were told their child has scoliosis after a school screening, adults who received a diagnosis decades apart with different numbers, and referring providers who want a second set of eyes on a curve.

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What Counts as a Scoliosis Diagnosis

A diagnosis of scoliosis rests on a standing radiograph. The working definition used in the 2016 SOSORT guidelines is a lateral curve of 10° or more measured by the Cobb method, with vertebral rotation present. A hump on a forward bend test, an uneven waistline, or a shoulder that sits high is a reason to image. None of those is the diagnosis.

That distinction matters because the screening tools were designed to over-refer. Bunnell's 1984 scoliometer study of 1,065 patients set an angle of trunk rotation of 5° as a threshold for identifying curves of 20° or more, with a projected false-negative rate of 0.1 percent. A tool tuned to miss almost nothing will flag children who turn out to have small curves or no structural curve at all. That is by design. The error happens when the flag is reported to the family as a diagnosis and no film follows, or when the film follows and nobody tells the family the screening result was a false alarm.

You can read more about how we interpret the angle on our Cobb angle page and in my post on how I read and track Cobb angles.

Error One: Progression That Is Really Measurement Noise

This is the misdiagnosis I see most. A child measures 18° in spring and 23° in fall, and the family is told the curve progressed. Maybe it did. The data on manual Cobb measurement say you cannot know from those two numbers alone.

Carman, Browne, and Birch at Texas Scottish Rite had experienced readers measure the same scoliosis films twice. The average difference between readings was 3.8°, 95 percent of differences fell at 8° or less, and they calculated that a change would need to reach 10° before you could be 95 percent confident it was real. Digital measurement on PACS with preselected end vertebrae does better. Srinivasalu and colleagues reported 95 percent confidence intervals around ±1.3° for intraobserver and interobserver variability. In congenital scoliosis the numbers get much worse. Loder's group found intraobserver variability of ±9.6° and interobserver variability of ±11.8°, because incompletely ossified and malformed end vertebrae are hard to mark.

The practical sources of noise I check on every comparison film:

• Were the same end vertebrae used on both studies? A different end vertebra choice can move the number several degrees by itself.
• Was the patient standing on both films? Supine films typically read smaller than standing films because gravity loading is removed.
• Was the pelvis level, or was a leg length difference left uncorrected on one study and corrected on the other?
• Was the film rotated? Patient rotation changes the projected geometry of the curve.
• Was the measurement made by the same reader with the same tools?

When those variables are controlled, a 5° change means more. When they are not, I would rather tell a family we need another controlled study than tell them a curve progressed or improved. The same rule applies to our own outcome reporting. A reduction claim is only as good as the consistency of the imaging behind it.

Error Two: A Functional Curve Called Scoliosis

A lateral curve on a standing film is not always structural. A leg length inequality tilts the pelvis, and the lumbar spine bends toward the short side to keep the head over the feet. That curve is real on the film, and it can measure above 10°, yet it is a compensation rather than a fixed deformity.

A 2026 systematic review in Spine by Truumees and colleagues looked at 24 cohort studies on telling spine-driven pelvic obliquity apart from limb-driven obliquity. The most useful discriminator was simple: place a block or lift under the short side and image again. A lumbar curve that resolves with the lift points to the leg. A curve that persists points to the spine. Mixed cases exist and are the hardest to sort out. I cover this in more detail in my post on postural versus structural curves.

Error Three: The Idiopathic Label Applied Too Early

Idiopathic means no cause was found. It is a diagnosis of exclusion, and the exclusion step gets skipped. Before I accept the label, I want a history and examination that would surface a congenital vertebral anomaly, a neuromuscular cause, or an intraspinal problem. Findings that change my plan include an atypical curve pattern, significant pain in a young patient, abnormal reflexes or other neurological signs, and rapid progression outside the expected growth window. Those patients get referred for advanced imaging and a medical opinion before any conservative plan starts. Our page on types of scoliosis and my post on what causes scoliosis cover the categories.

Error Four: The Missed Curve

The reverse error happens too. A child passes a quick screening, or nobody screens at all, and the curve is found at 35° after a growth spurt. The forward bend test depends on the examiner, the lighting, and whether the child is relaxed. Lumbar curves with little rotation can hide. This is part of why we run the Carolinas Scoliosis Screening Initiative and publish a free screening tool for parents.

How Dr. Justin Dick Reviews a Scoliosis Diagnosis at Clear Life

A second opinion at our Charlotte office starts with the prior films themselves, not the report. I want the images, the dates, and the positioning. Then I look at whether the original diagnosis holds up: whether the curve is structural, whether the measured change exceeds the error of the method, and whether the history fits an idiopathic pattern. Where new imaging is warranted, it is taken standing, with consistent positioning, so it can be compared to future films. Where it is not warranted, I say so. Our scoliosis second opinion page and imaging credentials page explain the process.

Comparison

Research and Evidence

The evidence cited here is mostly measurement and diagnostic-accuracy research, which is the right evidence type for this question. Carman 1990 and Loder 1995 are reliability studies with small reader groups. Srinivasalu 2008 used preselected end vertebrae, which removes one of the largest real-world sources of error, so its numbers represent a best case. The Truumees review is a systematic review of cohort studies with marked heterogeneity and no pooled estimate.

My own published work leans on careful radiographic measurement. The cervical mechanics study, A Retrospective Cross-Sectional Analysis of Abnormal Cervical Mechanics in Patients With Scoliosis (Cureus, 2025, PMID 41018459), used computer-aided measurement on 37 patients with scoliosis and found cervical alignment changes that a thoracolumbar-only film would miss. The 13-month follow-up case, Reduction of Adolescent Idiopathic Scoliosis: A 13-Month Follow-Up (Cureus, 2025, PMID 40062184), documents a Cobb change from 42.4° to 23.8°; a change of that size exceeds every published error threshold above, although it remains a single case. The full list is on my research page.

References

1. Negrini S, Donzelli S, Aulisa AG, et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord. 2018;13:3. doi:10.1186/s13013-017-0145-8
2. Bunnell WP. An objective criterion for scoliosis screening. J Bone Joint Surg Am. 1984;66(9):1381-7. PMID 6501335
3. Carman DL, Browne RH, Birch JG. Measurement of scoliosis and kyphosis radiographs. Intraobserver and interobserver variation. J Bone Joint Surg Am. 1990;72(3):328-33. PMID 2312528
4. Srinivasalu S, Modi HN, Smehta S, et al. Cobb angle measurement of scoliosis using computer measurement of digitally acquired radiographs: intraobserver and interobserver variability. Asian Spine J. 2008;2(2):90-3. doi:10.4184/asj.2008.2.2.90
5. Loder RT, Urquhart A, Steen H, et al. Variability in Cobb angle measurements in children with congenital scoliosis. J Bone Joint Surg Br. 1995;77(5):768-70. PMID 7559707
6. Truumees E, Akkihal K, Griffin J, et al. Differentiating spinal deformity versus leg length discrepancy in patients with pelvic obliquity: systematic review of diagnostic methods, imaging, and clinical management. Spine. 2026;51(12):E301-E312. doi:10.1097/BRS.0000000000005683
7. Dick JM. A retrospective cross-sectional analysis of abnormal cervical mechanics in patients with scoliosis. Cureus. 2025;17(8):e91098. doi:10.7759/cureus.91098
8. Dick JM, Spurgeon S. Reduction of adolescent idiopathic scoliosis: a 13-month follow-up. Cureus. 2025;17(2):e78669. doi:10.7759/cureus.78669

Frequently Asked Questions

Service Area

Clear Life Scoliosis and Chiropractic Center sees patients from Charlotte NC, Huntersville NC, Ballantyne NC, Matthews NC, Concord NC, Mooresville NC, Rock Hill SC, Fort Mill SC. Families from across the Charlotte region and the South Carolina border communities come to the Rachel Freeman Way office for radiographic scoliosis evaluation with Dr. Justin Dick.

Related Pages

• Scoliosis Second Opinion in Charlotte
• Radiographic Imaging Credentials
• Cobb Angle Explained
• Scoliosis Imaging and Measurement
• Types of Scoliosis
• Free Scoliosis Screening Tool
• Carolinas Scoliosis Screening Initiative
• Dr. Justin Dick Research
• Research and Evidence
• Treatment Options

Schedule an Evaluation in Charlotte

If your child or you were given a scoliosis diagnosis and the numbers do not add up, bring every prior film to our Charlotte office. Dr. Justin Dick will tell you what the images support and what they do not.

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