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Background: No comprehensive studies of bone stress injuries in the ankle and foot based on magnetic resonance imaging findings have been published.
Purpose: Using magnetic resonance imaging findings to assess incidence, location, and type of bone stress injuries of the ankle and foot in military conscripts with ankle and/or foot pain.
Study Design: Case series; Level of evidence, 4.
Methods: All patients with ankle or foot pain, negative findings on plain radiography, and magnetic resonance images obtained of the ankle or foot were included in this 86-month study. Magnetic resonance images with bone stress injury findings were re-evaluated regarding location and injury type. Based on the number of conscripts within the hospital catchment area, the person-based incidence of bone stress injuries was calculated.
Results: One hundred thirty-one conscripts displayed 378 bone stress injuries in 142 ankles and feet imaged, the incidence being 126 per 100 000 person-years. This incidence represents the stress injuries not diagnosable with radiographs and requiring magnetic resonance images. Of injuries, 57.7% occurred in the tarsal and 35.7% in the metatarsal bones. Multiple bone stress injuries in 1 foot were found in 63% of the cases. The calcaneus and fifth metatarsal bone were usually affected alone. Injuries to the other bones of the foot were usually associated with at least 1 other stress injury. The talus and calcaneus were the most commonly affected single bones. High-grade bone stress injury (grade IV–V) with a fracture line on magnetic resonance images occurred in 12% (talus, calcaneus), and low-grade injury (grade I–III) presented only as edema in 88% of the cases.
Conclusion: Multiple, various-stage bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults. When considering injuries that were missed by plain radiographs but detected by magnetic resonance imaging, the bones most often affected were the tarsal bones, of which the talus and calcaneus were the most prominent single bones and most common locations for higher grade (IV–V) bone stress injuries. With use of magnetic resonance imaging, early detection and grading of bone stress injuries are available, which enable early and appropriate injury management.
The ability of MRI scans to detect different water level content in soft tissues and bone (i.e. soft tissue and bone edema) has started to revolutionize our understanding of many foot and lower extremity injuries. For example, a very nicely done MRI study from 12 years ago of medial tibial stress syndome and medial tibial stress fractures showed a continuum between the two injuries which now leads many to believe that medial tibial stress syndome is a precursor to medial tibial stress fracture (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, 23:472-481, 1995).
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Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system
M Fredericson, AG Bergman, KL Hoffman and MS Dillingham
Department of Functional Restoration, Stanford University Medical Center, CA 94305, USA.
Medial tibial pain in runners has traditionally been diagnosed as either a shin splint syndrome or as a stress fracture. Our work using magnetic resonance imaging suggests that a progression of injury can be identified, starting with periosteal edema, then progressive marrow involvement, and ultimately frank cortical stress fracture. Fourteen runners, with a total of 18 symptomatic legs, were evaluated and, within 10 days, referred for radiographs, a technetium bone scan, and a magnetic resonance imaging scan. In 14 of the 18 symptomatic legs, magnetic resonance imaging findings correlated with an established technetium bone scan grading system and more precisely defined the anatomic location and extent of injury. We identified clinical symptoms, such as pain with daily ambulation and physical examination findings, including localized tibial tenderness and pain with direct or indirect percussion, that correlated with more severe tibial stress injuries. When clinically warranted, we recommend magnetic resonance imaging over bone scan for grading of tibial stress lesions in runners. Magnetic resonance imaging is more accurate in correlating the degree of bone involvement with clinical symptoms, allowing for more accurate recommendations for rehabilitation and return to impact activity. Additional advantages of magnetic resonance imaging include lack of exposure to ionizing radiation and significantly less imaging time than three-phase bone scintigraphy.
In addition, I now include a clinical diagnosis of "metatarsal shaft stress syndrome" (i.e. pre-stress fracture of metatarsal) in my office notes and during my lectures that is based on the significant bone marrow edema seen on MRI in the affected metatarsal shafts of symptomatic individuals. Here's another article on how MRI is being used to help prevent of metatarsal stress fractures in high level competetive athletes.
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Major, Nancy M: Role of MRI in Prevention of Metatarsal Stress Fractures in Collegiate Basketball Players. American Journal of Radiology, 186:255-258, 2006.
OBJECTIVE. Metatarsal stress fractures are common and represent debilitating and potentially season-ending injuries for basketball players. Bone marrow edema is readily visualized on MRI and can be a sign of stress changes. Twenty-six asymptomatic male National Collegiate Athletic Association basketball players were imaged before the 2003-2004 season and 14 players were reimaged after the conclusion of the season with a screening study of long- and short-axis fat-suppressed T2-weighted images (TR/effective TE, 3,500/56) to identify bone marrow edema in the metatarsals.
CONCLUSION. Six (12%) of 52 feet showed a signal indicating bone marrow edema in the metatarsals. MRI depicts bone marrow edema in the feet before a fracture becomes evident. Identification of this edema may reveal stress changes, allowing early treatment and prevention of debilitating stress fractures.
I believe MRI scanning will continue to greatly reshape many of our ideas about the diagnosis, etiology, prevention and treatment of injuries in the foot and lower extremity in the coming years.
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Sincerely,
Kevin
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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Bone stress injury of the ankle in professional ballet dancers seen on MRI.
Elias I, Zoga AC, Raikin SM, Peterson JR, Besser MP, Morrison WB, Schweitzer ME BMC Musculoskelet Disord. 2008 Mar 28;9(1):39
Quote:
BACKGROUND: Ballet Dancers have shown to have a relatively high incidence of stress fractures of the foot and ankle. It was our objective to examine MR imaging patterns of bone marrow edema (BME)in the ankles of high performance professional ballet dancers, to evaluate clinical relevance.
METHODS: MR Imaging was performed on 12 ankles of 11 active professional ballet dancers(6 female, 5 male; age 19 to 32 years, average age 24). Individuals were imaged on a 0.2T or 1.5T MR units. Images were evaluated by two musculoskeletal radiologists and one orthopaedic surgeon in consensus for location and pattern of bone marrow edema. In order to control for recognized sources of bone marrow edema, images were also reviewed for presence of osseous, ligamentous, tendinous and for cartilaginous injuries. Statistical analysis was performed to assess the strength of the correlation between bone marrow edema and ankle pain.
RESULTS: Bone marrow edema was seen only in the talus, and was a common finding, observed in nine of the twelve ankles imaged (75%) and was 100% associated with pain. On fluid-sensitive sequences, bone marrow edema was ill-defined and centered in the talar neck or body, although in three cases it extended to the talar dome. No apparent gender predilection was noted. No occult stress fracture could be diagnosed. A moderately strong correlation (phi = .77, p=.0054) was found between edema and pain in the study population.
CONCLUSION: Bone marrow edema seems to be a specific MRI finding in the talus of professional ballet dancers, likely related to biomechanical stress reactions, due to their frequently performed unique maneuvers. Clinically, this condition may indicate a sign of an overuse syndrome of the ankle.
Bone stress injury
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