The Scintigraphic Diagnosis of Stress Fractures in the Lower Extremity
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Published:
Apr 30, 2012
Keywords:
Stress fracture fatigue fracture bone scan bone scintigraphy
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Abstract
Stress fractures are usually found in athletes and military populations. They occur more commonly in the lower extremity. The most commonly involved bone is the tibia, and is frequently associated with running activities. Diagnosis is often difficult, and may be missed due to the limited sensitivity of plain radiographs. Magnetic resonance imaging (MRI) is the gold standard for the diagnosis of stress fractures. Three-phase radionuclide bone scintigraphy is another imaging modality: it is highly sensitive, simple and safe. Thus, it can be used solely, or complementary to MRI.
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References
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2. Patel DR. Stress fractures: diagnosis and management in the primary care setting. Pediatr Clin North Am 2010; 57(3): 819-27.
3. Bergman AG, Fredericson M. MR imaging of stress reactions, muscle injuries, and other overuse injuries in runners. Magn Reson Imaging Clin N Am 1999; 7(1): 151-74.
4. Protzman RR. Physiologic performance of women compared to men. Observations of cadets at the United States Military Academy. Am J Sports Med 1979; 7(3): 191-4.
5. Pester S, Smith PC. Stress fractures in the lower extremities of soldiers in basic training. Orthop Rev 1992; 21(3): 297-303.
6. Bijur PE, Horodyski M, Egerton W, Kurzon M, Lifrak S, Friedman S. Comparison of injury during cadet basic training by gender. Arch Pediatr Adolesc Med 1997; 151(5): 456-61.
7. Gam A, Goldstein L, Karmon Y, Mintser I, Grotto I, Guri A, et al. Comparison of stress fractures of male and female recruits during basic training in the Israeli anti-aircraft forces. Mil Med 2005; 170(8): 710-2.
8. Courtenay BG, Bowers DM. Stress fractures: clinical features and investigation. Med J Aust 1990; 153(3): 155-6.
9. Dixon S, Newton J, Teh J. Stress fractures in the young athlete: a pictorial review. Curr Probl Diagn Radiol 2011; 40(1): 29-44.
10. Orava S, Jormakka E, Hulkko A. Stress fractures in young athletes. Arch Orthop Trauma Surg 1981; 98(4): 271-4.
11. Daffner RH, Pavlov H. Stress fractures: current concepts. Am J Roentgenol 1992; 159(2): 245-52.
12. Bennell KL, Brukner PD. Epidemiology and site specificity of stress fractures. Clin Sports Med 1997; 16(2): 179-96.
13. Hootman JM, Macera CA, Ainsworth BE, Martin M, Addy CL, Blair SN. Predictors of lower extremity injury among recreationally active adults. Clin J Sport Med 2002; 12(2): 99-106.
14. Orava S, Puranen J, Ala-Ketola L. Stress fractures caused by physical exercise. Acta Orthop Scand 1978; 49(1): 19-27.
15. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med 1987; 15(1): 46-58.
16. Zwas ST, Elkanovitch R, Frank G. Interpretation and classification of bone scintigraphic findings in stress fractures. J Nucl Med 1987; 28(4): 452-7.
17. Jones BH, Harris JM, Vinh TN, Rubin C. Exercise-induced stress fractures and stress reactions of bone: epidemiology, etiology, and classification. Exerc Sport Sci Rev 1989; 17: 379-422.
18. Key VH. Leg pain in runners. Current Opinion in Orthopaedics 2007; 18(2): 161-5.
19. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician 2011; 83(1): 39-46.
20. Wall J, Feller JF. Imaging of stress fractures in runners. Clin Sports Med 2006; 25(4): 781-802.
21. Prather JL, Nusynowitz ML, Snowdy HA, Hughes AD, McCartney WH, Bagg RJ. Scintigraphic findings in stress fractures. J Bone Joint Surg Am 1977; 59(7): 869-74.
22. Greaney RB, Gerber FH, Laughlin RL, Kmet JP, Metz CD, Kilcheski TS, et al. Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology 1983; 146(2): 339-46.
23. Mulligan ME. The "gray cortex ": an early sign of stress fracture. Skeletal Radiol 1995; 24(3): 201-3.
24. Rupani HD, Holder LE, Espinola DA, Engin SI. Three-phase radionuclide bone imaging in sports medicine. Radiology 1985; 156(1): 187-96.
25. Brukner P, Bradshaw C, Khan KM, White S, Crossley K. Stress fractures: a review of 180 cases. Clin J Sport Med 1996; 6(2): 85-9.
26. Ohta-Fukushima M, Mutoh Y, Takasugi S, Iwata H, Ishii S. Characteristics of stress fractures in young athletes under 20 years. J Sports Med Phys Fitness 2002; 42(2): 198-206.
27. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 1995; 23(4): 472-81.
28. Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high performance athletes. Clin Sports Med 1997; 16(2): 291-306.
29. Gaeta M, Minutoli F, Scribano E, Ascenti G, Vinci S, Bruschetta D, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology 2005; 235(2): 553-61.
30. Markey KL. Stress fractures. Clin Sports Med 1987; 6(2): 405-25.
31. Holder LE, Michael RH. The specific scintigraphic pattern of "shin splints in the lower leg": concise communication. J Nucl Med 1984; 25(8): 865-9.
32. Van der Wall H, Lee A, Magee M, Frater C, Wijesinghe H, Kannangara S. Radionuclide bone scintigraphy in sports injuries. Semin Nucl Med 2010; 40(1): 16-30.
33. Hirschmann MT, Davda K, Rasch H, Arnold MP, Friederich NF. Clinical value of combined single photon emission computerized tomography and conventional computer tomography (SPECT/CT) in sports medicine. Sports Med Arthrosc 2011; 19(2): 174-81.
2. Patel DR. Stress fractures: diagnosis and management in the primary care setting. Pediatr Clin North Am 2010; 57(3): 819-27.
3. Bergman AG, Fredericson M. MR imaging of stress reactions, muscle injuries, and other overuse injuries in runners. Magn Reson Imaging Clin N Am 1999; 7(1): 151-74.
4. Protzman RR. Physiologic performance of women compared to men. Observations of cadets at the United States Military Academy. Am J Sports Med 1979; 7(3): 191-4.
5. Pester S, Smith PC. Stress fractures in the lower extremities of soldiers in basic training. Orthop Rev 1992; 21(3): 297-303.
6. Bijur PE, Horodyski M, Egerton W, Kurzon M, Lifrak S, Friedman S. Comparison of injury during cadet basic training by gender. Arch Pediatr Adolesc Med 1997; 151(5): 456-61.
7. Gam A, Goldstein L, Karmon Y, Mintser I, Grotto I, Guri A, et al. Comparison of stress fractures of male and female recruits during basic training in the Israeli anti-aircraft forces. Mil Med 2005; 170(8): 710-2.
8. Courtenay BG, Bowers DM. Stress fractures: clinical features and investigation. Med J Aust 1990; 153(3): 155-6.
9. Dixon S, Newton J, Teh J. Stress fractures in the young athlete: a pictorial review. Curr Probl Diagn Radiol 2011; 40(1): 29-44.
10. Orava S, Jormakka E, Hulkko A. Stress fractures in young athletes. Arch Orthop Trauma Surg 1981; 98(4): 271-4.
11. Daffner RH, Pavlov H. Stress fractures: current concepts. Am J Roentgenol 1992; 159(2): 245-52.
12. Bennell KL, Brukner PD. Epidemiology and site specificity of stress fractures. Clin Sports Med 1997; 16(2): 179-96.
13. Hootman JM, Macera CA, Ainsworth BE, Martin M, Addy CL, Blair SN. Predictors of lower extremity injury among recreationally active adults. Clin J Sport Med 2002; 12(2): 99-106.
14. Orava S, Puranen J, Ala-Ketola L. Stress fractures caused by physical exercise. Acta Orthop Scand 1978; 49(1): 19-27.
15. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med 1987; 15(1): 46-58.
16. Zwas ST, Elkanovitch R, Frank G. Interpretation and classification of bone scintigraphic findings in stress fractures. J Nucl Med 1987; 28(4): 452-7.
17. Jones BH, Harris JM, Vinh TN, Rubin C. Exercise-induced stress fractures and stress reactions of bone: epidemiology, etiology, and classification. Exerc Sport Sci Rev 1989; 17: 379-422.
18. Key VH. Leg pain in runners. Current Opinion in Orthopaedics 2007; 18(2): 161-5.
19. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician 2011; 83(1): 39-46.
20. Wall J, Feller JF. Imaging of stress fractures in runners. Clin Sports Med 2006; 25(4): 781-802.
21. Prather JL, Nusynowitz ML, Snowdy HA, Hughes AD, McCartney WH, Bagg RJ. Scintigraphic findings in stress fractures. J Bone Joint Surg Am 1977; 59(7): 869-74.
22. Greaney RB, Gerber FH, Laughlin RL, Kmet JP, Metz CD, Kilcheski TS, et al. Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology 1983; 146(2): 339-46.
23. Mulligan ME. The "gray cortex ": an early sign of stress fracture. Skeletal Radiol 1995; 24(3): 201-3.
24. Rupani HD, Holder LE, Espinola DA, Engin SI. Three-phase radionuclide bone imaging in sports medicine. Radiology 1985; 156(1): 187-96.
25. Brukner P, Bradshaw C, Khan KM, White S, Crossley K. Stress fractures: a review of 180 cases. Clin J Sport Med 1996; 6(2): 85-9.
26. Ohta-Fukushima M, Mutoh Y, Takasugi S, Iwata H, Ishii S. Characteristics of stress fractures in young athletes under 20 years. J Sports Med Phys Fitness 2002; 42(2): 198-206.
27. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 1995; 23(4): 472-81.
28. Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high performance athletes. Clin Sports Med 1997; 16(2): 291-306.
29. Gaeta M, Minutoli F, Scribano E, Ascenti G, Vinci S, Bruschetta D, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology 2005; 235(2): 553-61.
30. Markey KL. Stress fractures. Clin Sports Med 1987; 6(2): 405-25.
31. Holder LE, Michael RH. The specific scintigraphic pattern of "shin splints in the lower leg": concise communication. J Nucl Med 1984; 25(8): 865-9.
32. Van der Wall H, Lee A, Magee M, Frater C, Wijesinghe H, Kannangara S. Radionuclide bone scintigraphy in sports injuries. Semin Nucl Med 2010; 40(1): 16-30.
33. Hirschmann MT, Davda K, Rasch H, Arnold MP, Friederich NF. Clinical value of combined single photon emission computerized tomography and conventional computer tomography (SPECT/CT) in sports medicine. Sports Med Arthrosc 2011; 19(2): 174-81.