Improving Diagnostic Accuracy and Efficiency of Suspected Bone Stress Injuries

Abstract

Context:Lower extremity stress fractures among athletes and military recruits cause significant morbidity, fiscal costs, and time lost from sport or training. During fiscal years (FY) 2012 to 2014, 1218 US Air Force trainees at Joint Base San Antonio–Lackland, Texas, were diagnosed with stress fracture(s). Diagnosis relied heavily on bone scans, often very early in clinical course and often in preference to magnetic resonance imaging (MRI), highlighting the need for an evidence-based algorithm for stress injury diagnosis and initial management.Evidence Acquisition:To guide creation of an evidence-based algorithm, a literature review was conducted followed by analysis of local data. Relevant articles published between 1995 and 2015 were identified and reviewed on PubMed using search terms stress fracture, stress injury, stress fracture imaging, and stress fracture treatment. Subsequently, charts were reviewed for all Air Force trainees diagnosed with 1 or more stress injury in their outpatient medical record in FY 2014.Study Design:Clinical review.Level of Evidence:Level 4.Results:In FY 2014, 414 trainees received a bone scan and an eventual diagnosis of stress fracture. Of these scans, 66.4% demonstrated a stress fracture in the symptomatic location only, 21.0% revealed stress fractures in both symptomatic and asymptomatic locations, and 5.8% were negative in the symptomatic location but did reveal stress fracture(s) in asymptomatic locations. Twenty-one percent (18/85) of MRIs performed a mean 6 days (range, 0- 21 days) after a positive bone scan did not demonstrate any stress fracture.Conclusion:Bone stress injuries in military training environments are common, costly, and challenging to diagnose. MRI should be the imaging study of choice, after plain radiography, in those individuals meeting criteria for further workup.

Conservative versus surgical treatment of 21 sports horses with osseous trauma in the proximal phalangeal sagittal groove diagnosed by low‐field MRI

“…Many studies seeking to improve diagnostic accuracy and efficacy of stress-related injuries in human athletes have compared the ability of MRI and CT to detect stress reaction and stress fractures. [19][20][21][22][23] In human medicine, high-field MRI is considered the test of choice for early diagnosis of bone stress injuries. 20 Increased water content within the bone, which is considered the earliest macroscopic change associated with stress injury, is visible on MRI within approximately 1 to 3 days of onset of pain.…”

“…[19][20][21][22][23] In human medicine, high-field MRI is considered the test of choice for early diagnosis of bone stress injuries. 20 Increased water content within the bone, which is considered the earliest macroscopic change associated with stress injury, is visible on MRI within approximately 1 to 3 days of onset of pain. 21 In contrast, CT is largely unable to detect bone turnover or changes in bone water content, which limits its utility for early diagnosis of stress fractures.…”

“…As previously discussed, MRI is the imaging modality of choice for detection of early stressrelated changes within the bone, but CT is superior in defining fracture configuration. 20,23 It is possible that low-field MRI did not detect all the incomplete PP fractures, and this could have negatively affected the surgically planning. In addition, low-field MRI does not detect articular cartilage abnormalities.…”

A Review and Proposed Rationale for the use of Ultrasonography as a Diagnostic Modality in the Identification of Bone Stress Injuries

“…The rate of bone stress injuries, which are common in military personnel and athletes, has increased during the past 25 years because of the greater physical demands required of athletes in all levels of sports, especially in those training for endurance events . According to several epidemiologic studies published by the United States military, the incidence of bone stress injuries accounted for 0.8% to 6.9% of entry‐level male military trainees and 2.4% to 21.0% of female trainees . Both military and athletic population studies support a greater risk of sustaining bone stress injuries in women .…”

Bilateral iliac stress fracture in a young male military cadet: report of an unusual case

“…Their incidence depends on the sex and is higher in females. Especially, in the military population, as our patient, the incidence varies between 0.8-6.8% for males and 2.6-21% for female recruits [5][6][7] . Interestingly, female recruits have a bone injury rate 1.5 to 5 times higher than males following the same training program 6 .…”