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Press Release: 'Therapeutic Ultrasound' Shows Bone Stress Injuries
NEW YORK (Reuters Health) Mar 29 - So-called therapeutic ultrasound, commonly used to treat soft tissue injuries, can be an alternative to magnetic resonance imaging (MRI) for detecting bone stress injuries, according to a British research team.
"We are not talking about ultrasound imaging, but therapeutic ultrasound, i.e., the stuff that physiotherapists use," said senior author Dr. Nicola Maffulli in an email.
Dr. Maffulli, from Barts and The London School of Medicine and Dentistry, and colleagues compared therapeutic ultrasound with MRI in 113 elite track and field athletes with clinical suspicion of bone stress injury.
MRI - the gold standard -- "is not always available, it is not portable, and it requires time and a specialized setting," Dr. Maffulli told Reuters Health. "Ultrasound obviates all these issues and can be used in the field."
On MRI, three athletes (2.7%) were normal, six (5.3%) had stress fractures, and the rest had intermediate bone stress injuries manifested by periosteal edema and marrow signal abnormalities. Five athletes had multiple bone stress injuries.
Compared with MRI, therapeutic ultrasound showed 81.8% sensitivity, 66.6% specificity, 99.0% positive predictive value, 13.4% negative predictive value, and 81.4% accuracy for the diagnosis of stress injuries, according to a report online February 23rd in The American Journal of Sports Medicine.
Sensitivity was much higher for grade 3 injuries and actual stress fractures (95.1%) than for lower grade (1 and 2) bone stress injuries (44%).
"In the past, therapeutic ultrasound has been proposed as a cost-effective, alternative investigative tool for the diagnosis of stress fractures," the investigators wrote. "Therapeutic ultrasound can be performed by physical therapists or athletic trainers in medical facilities of training centers as soon as the clinician suspects the presence of a stress fracture or a stress reaction."
"Further studies should be undertaken to assess sensitivity and specificity of therapeutic ultrasound in different locations and to correlate therapeutic ultrasound with each MRI grade," the authors conclude.
In the meantime, Dr. Maffulli said, "Given the results that we produced, we have now essentially discarded MRI as the primary investigation when we suspect such conditions. We still use MRI in dubious/complex cases."
Also, he said, "We plan to use ultrasound as a monitoring tool in patients who suffered a stress reaction and are rehabilitating from it."
Ultrasound as a Primary Evaluation Tool of Bone Stress Injuries in Elite Track and Field Athletes
Agapi Papalada, Nikolaos Malliaropoulos, Kostas Tsita, Olga Kiritsi, Nat Padhiar, Angelo Del Buono, Nicola Maffulli Am J Sports Med February 23, 2012 0363546512437334
Background: Little is known about therapeutic ultrasound (TUS) to diagnose bone stress injuries.
Hypothesis: Therapeutic ultrasound is an accurate, cost-efficient alternative to other imaging methods for primary assessment of bone stress injuries.
Study Design: Cohort study (diagnosis); Level of evidence, 2.
Methods: One hundred thirteen elite track and field athletes (mean age, 20.1 years; range, 17-28 years) underwent TUS and magnetic resonance imaging (MRI) for clinical suspicion of a bone stress injury. A 5-stage MRI grading system was used to classify bone stress injuries. Sensitivity, specificity, accuracy, and positive and negative predictive values of TUS were calculated using MRI as the standard for diagnosis.
Results: At MRI, of 113 assessed patients, 3 (2.7%) had grade 0 injuries, 12 (10.6%) had grade 1, 15 (13.3%) had grade 2, 77 (68.2%) had grade 3, and 6 (5.3%) had grade 4. At TUS, no injury was detected in 22 of 113 patients: 2 with grade 0 injury, 8 with grade 1, 8 with grade 2, and 4 with grade 3. Using MRI as the gold standard, TUS showed 81.8% sensitivity, 66.6% specificity, 99.0% positive predictive value, 13.4% negative predictive value, and 81.4% accuracy.
Conclusion: Therapeutic ultrasound is a reproducible procedure that is reliable to diagnose bone stress injuries.