Stress Fractures and Related Disorders in Foot and Ankle: Plain Films, Scintigraphy, CT, and MR Imaging

Abstract

The accurate diagnosis of stress-induced changes in the foot and ankle requires careful and detailed clinical history and examination. This is of paramount importance in ensuring the correct imaging interpretation and for excluding other differential diagnoses. Advanced imaging (scintigraphy and MR imaging) plays a vital role in the early diagnosis of this type of injury, and CT has an important contributory role in the diagnosis of injury where imaging features by the other modalities are equivocal. An early diagnosis reached by judicious use of imaging techniques is the cornerstone of appropriate management, with a high probability of a full recovery, a low risk of complications, and a return to pre-disease activity.

Stress-related bone injuries with emphasis on MRI

“…2). 20,21 This sensitivity of MRI relies on the ability to detect early bone marrow oedema, the hallmark of the stress response. 17,22 A grading system developed by Kiuru et al 23 (Table 4) demonstrates how the sequential detection of oedema using STIR, T2WIs and T1WIs increases as the severity of the stress response increases.…”

Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options

“…In addition to the increased incidence of stress fractures in women, they tend to show a different distribution of injury, with the female pelvis and metatarsals more common, and the fibula less affected [24]. For foot and ankle overuse injuries, other potential contributing factors include malalignments (hyper/hypo-pronation, pes planus/cavus, forefoot or hindfoot varus/valgus, tibia vara, genu valgum/ varum), limb length discrepancies, tarsal coalition, previous surgeries or trauma to the same or opposite limb, joint laxity or instability, and muscles weakness or imbalance [25]. All of these factors can alter the complex biomechanics and weightbearing dynamics of the lower extremity and place undo stresses on one bone or set of bones to compensate for these alignment abnormalities or other deficiencies.…”

“…Several predisposing factors have been identified as the cause of insufficiency fractures with the common entity often being osteoporosis (primary or secondary). Other risk factors include rheumatoid arthritis, metabolic bone disease, neurological disorders, prior irradiation, total hip replacement, corticosteroid therapy, high-dose fluoride therapy, and bisphosphonate therapy, among others [6,7,25,27]. In these situations, bone elasticity and mineral content are compromised.…”

“…On conventional radiographs, the differential diagnosis of stress injuries includes normal cortical thickening, normal nutrient artery channel, osteomyelitis/Brodie abscess, osteoid osteoma, other neoplasms (e.g., surface osteosarcoma or metastasis), osteitis pubis, and avascular necrosis [25]. This differential diagnosis is summarized in Table 4.…”

Weightbearing CBCT, MDCT, and 2D imaging dosimetry of the foot and ankle

“…Multiple views are required and often are unsatisfactory due to superimposition of multiple adjacent bones that form the complex skeletal structure of this anatomy [3] . Multi-detector Computed Tomography (MDCT) is an good diagnostic alternative and permits isolation and visualization of separate bony structures [4,5] ; however, this examination is expensive, limited in availability to hospitals and large radiology practices, and is associated with significantly increased x-ray dose in relation to plain views.…”