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Stress fractures and bone pain: are they closely associated?
526
lnjyry (1985) 16, 526-528
Printed in Great Britain
Stress fractures and bone pain: are they closely associated? David Groshar, Menahem Rambam
Medical
Lam, Einat Even-Sapir, Ora Israel and Dov Front
Center and Technion-Israel
Institute
Summary The relationship between bone pain and stress fractures diagnosed by bone scintigraphy was investigated in military recruits during active training. In three patients pain appeared in the site of abnormal uptake 7-14 days after the bone scan in a previously asymptomatic site. One hundred and twenty-four sites of stress fractures were found in 64 patients; 32 (26 per cent) were asymptomatic. In 38 patients (59 per cent) there were multiple stress fractures; 32 (33 per cent) had asymptomatic stress fractures. Fifty-three per cent of the regions with abnormal uptake in the femur were painless, compared with 17 per cent in the tibia. The necessity for imaging all bones susceptible to stress fractures, even when asymptomatic, is stressed. It is suggested that diagnosis of stress fracture should be made when typical abnormal uptake appea.rs on scintigraphy. Bone pain in such cases may be delayed.
INTRODUCTION EARLY diagnosis of stress fracture is possible by bone scintigraphy (Wilcox et al., 1977; Roub et al., 1979; Norfray et al., 1980; Daffner et al., 1982; Holder, 1982; Rosen et al., 1982; Granary et al., 1983). Pain during physical activity is the main symptom which alerts the physician to such a fracture. Our attention was drawn to the relationship between stress fracture and bone pain by three patients who were asymptomatic at the time that a bone scan revealed a stress fracture but who later developed pain at the site of abnormal uptake by bone. To answer this question we analysed retrospectively the bone scans of 64 patients studied for stress fracture.
MATERIAL AND METHODS The medical charts and bone scans of 64 military recruits aged 18-21 (average age 19 years) were reviewed retrospectively in order to correlate bone pain and areas of increased uptake in bone scintigraphy. All complained of localized pain in the lower limbs during exercise. Patients with a history of injury to the bone were excluded. Bone scintigraphy was carried out 2-3 hours after the injection of 15-20 mCi of -cmintravenous methylene-diphosphonate (Tc-MDP). A digital, large field-of-view gamma camera with a high resolution Dr Groshar is recipient of a fellowship from the International Atomic Energy Agency (Vienna), supported by the Brazilian Nuclear Energy Commission and the Atomic Energy Commission of Israel.
of Technology,
Haifa, Israel
collimator (Apex, Elscint Inc., Israel) was used to obtain 500 000 counts’ images of the pelvis and 300 000 counts of the lower limbs in the anterior view. When required, lateral, medial and posterior views were added. RESULTS A localized, well-defined, spindle-shaped, intense abnormal uptake was considered to indicate a stress fracture (Roub et al., 1979; Holder, 1982; Rosen et al., 1982). Diffuse, ill-defined areas of increased uptake were not so considered. The sites of abnormal uptake in the scintigrams were compared with the regions of localized pain. One hundred and twenty-four sites of stress fractures in the lower limbs were found in the 64 patients; 32 (26 per cent) caused no symptoms (Table I); in 38 patients (59 per cent) there were multiple sites of stress fractures, 32 (33 per cent) of these were asymptomatic (Table II). Twenty-six patients had a single symptomatic stress fracture. In three patients pain appeared in a previously asymptomatic site 7-14 days after the bone scan. These cases are now described. Tab/e 1. Distribution of sites with increased uptake and bone pain in 64 military recruits with stress fractures
Region of fracture Femur Proximal Medial Distal Total Tibia Proximal Medial Distal Total Fibula Medial Distal Total Tarsal bones Metatarsal bones Total
Abnormal Abnormal scintigraph y scintigraphy with pain without pain
3 11
8
Total
11 11
1: (47%)
179(53%)
Z (100%)
7 53
3 11
10 64
6: (83%)
14 (17%)
8: (100%)
1 3 (100%) 2 (100%) 3 (75%) 92 (74%)
1 0 ; (25%)
3 (100%) 2 (100%) 4 (100%)
32 (26%)
124 (100%)
Groshar et al.: Stress fractures and bone pain
527
Tab/e II. Distribution of sites with increased 38 subjects with multiple stress fractures Tibia Femur Pain Increased focal uptake
51 65
Fibula
10 27
CASE REPORTS An l&year-old military recruit was investigated after 4 weeks of training because he had pain in both feet during exercise. Bone scintigraphy showed increased uptake in the middle thirds of both tibias (Fig. 1). No abnormal uptake was seen in his feet. He was instructed to avoid exercise. One week later pain and tenderness came on in the middle third of his left tibia where the bone scan was positive.
Case 2 An l&year-old military recruit complained of pain in the distal third of his left tibia 6 weeks after he began training. Bone scintigraphy revealed abnormal uptake in the distal third of the left tibia and in the distal third of the right femur. The patient continued training, though less vigorously. Two weeks later during exercise he felt pain in the distal third of his right femur, at the site which previously showed abnormal uptake. Case 3 weeks after starting his training an l&year-old military recruit was investigated for pain in the dorsal aspect of the left foot during exercise. Scintigraphy showed increased uptake in the right first metatarsal bone and the lateral condyle of the left tibia. Physical activity was reduced. Ten days later he complained of pain in the left knee, with tenderness on the lateral aspect of the uppermost third of the left tibia, at the site which previously showed abnormal uptake. Three
result
and bone pain in
Tarsus Metatarsus
2 2
1 1
2 3
Total 66 98
that causes absorption of bone in excess of repair and bone formation in certain regions (Not-fray et al., 1980). The continual stress on the weakened bone leads to cortical and trabecular disruption, and subsequently to a fracture (Wilcox et al., 1977; Meurman and Eleving, 1980; Norfray et al., 1980; Granary et al., 1983). The typical clinical feature is the onset of pain during physical activity; this worsens if the activity continues and is relieved by rest. The early recognition of a stress fracture is essential in order to avoid severe injury to the bone. Radiography is much less sensitive than bone scanning for diagnosis of stress fracture (Geslien et al., 1976; Meurman and Eleving, 1980; Granary et al., 1983). Only 28 per cent of the cases will be positive in the early stages and as many as 50 per cent will be missed by radiography, even several weeks after the appearance of symptoms or after a positive bone scan (Granary et al., 1983). Many studies demonstrate the usefulness of bone scanning in the early diagnosis of stress fractures, with a reported sensitivity of 100 per cent (Roub et al., 1979; Belkin, 1980; Granary et al., 1983). Bone scintigraphy thus establishes the diagnosis in patients complaining of bone pain (Roub et al., 1979; Belkin, 1980; Holder, 1982; Granary et al., 1983). The three patients reported herein suggest the possibility that the abnormality on scintigraphy of bone may appear earlier than pain. Even when certain areas of abnormal uptake may be associated with pain, others may temporarily be painless. Asymptomatic stress fractures are more common in the femur than in the tibia; 53 per cent of the regions with abnormal uptake in the femur were painless, compared with 17 per cent in the tibia. The results of this study stress the necessity for scintigraphy of all susceptible bones in a population prone to stress fractures. While our material does not indicate the percentage of patients having stress fractures without pain in such a population, it does prove that there may be a delay between the onset of pain after the diagnosis has already been established by scintigraphy. We do not suggest that scintigraphy of bone should be done routinely in all military recruits or people starting on a jogging piogramme. It is our aim to draw attention to the fact that abnormal uptake indicating stress fracture may appear in the absence of pain, which will occur only later. The appearance of asymptomatic scintigraphic lesions is not confined to stress fractures and we have previously described this phenomenon in bone metastases (Front et al., 1979). activity
Case 1
DISCUSSION Stress fractures
uptake
from unusual,
repeated
physical
Fig. 1. ?cm-MDP bone scintigraphy of distal part of lower extremities. Two areas of abnormal, spindle-shape uptake in the middle third of both tibias are seen,
Acknowledgement We express our thanks to Dr Steven Baron for reviewing the manuscript.
528
REFERENCES Belkin S. C. (1980) Stress fractures in athletes. Orfhop. Clin. North Am. 11(4), 735. Daffner R. H., Martinez S. and Gehweiler J. A. (1982) Stress fractures in runners. JAMA 247, 1039. Front D., Schneck S. O., Frankel A. et al. (1979) Bone metastases and bone pain in breast cancer: are they closely associated? JAMA 242, 1747. Geslien G. E., Thrall J. H., Espinosa J. L. et al. (1976) Early detection of stress fractures using 99mTc-polyphosphate. Radiology 121, 683.
Granary R. B., Gerber F. H., Laughlin R. L. et al. (1983) Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology 146, 339. Holder L. E. (1982) Radionuclide bone-imaging in the evaluation of bone pain. J. Bone Joint Surg. 64A, 1391.
Injury: the British Journal of Accident Surgery (1985) Vol. 18/No. 8
Meurman K. 0. A. and Eleving S. (1980) Stress fracture in soldiers: a multifocal bone disorder. Radiology 134, 483. Norfray J. F., Schlachter L., Kernahan W. T. et al. (1980) Early confirmation of stress fractures in joggers. JAMA 243, 1647.
Rosen P. R., Micheli L. J. and Treves S. (1982) Early scintigraphic diagnosis of bone stress and fractures in athletic adolescents. Pediatrics 70, 11. Roub L. W., Gumerman L. W., Hanley E. N. et al. (1979) Bone stress: a radionuclide imaging perspective. Radiology 132, 431.
Wilcox J. R., Moniot A. L. and Green J. P. (1977) Bone scanning in the evaluation of exercise-related stress injuries. Radiology 123, 699. Paper accepted
I1 January 1985.
Requm for reprim should he uddwssed to: Dr D. Front, Department of Nuclear Medicine, Rambam Medical Center, Haifa 3.5254, Israel.
lnjyry (1985) 16, 526-528
Printed in Great Britain
Stress fractures and bone pain: are they closely associated? David Groshar, Menahem Rambam
Medical
Lam, Einat Even-Sapir, Ora Israel and Dov Front
Center and Technion-Israel
Institute
Summary The relationship between bone pain and stress fractures diagnosed by bone scintigraphy was investigated in military recruits during active training. In three patients pain appeared in the site of abnormal uptake 7-14 days after the bone scan in a previously asymptomatic site. One hundred and twenty-four sites of stress fractures were found in 64 patients; 32 (26 per cent) were asymptomatic. In 38 patients (59 per cent) there were multiple stress fractures; 32 (33 per cent) had asymptomatic stress fractures. Fifty-three per cent of the regions with abnormal uptake in the femur were painless, compared with 17 per cent in the tibia. The necessity for imaging all bones susceptible to stress fractures, even when asymptomatic, is stressed. It is suggested that diagnosis of stress fracture should be made when typical abnormal uptake appea.rs on scintigraphy. Bone pain in such cases may be delayed.
INTRODUCTION EARLY diagnosis of stress fracture is possible by bone scintigraphy (Wilcox et al., 1977; Roub et al., 1979; Norfray et al., 1980; Daffner et al., 1982; Holder, 1982; Rosen et al., 1982; Granary et al., 1983). Pain during physical activity is the main symptom which alerts the physician to such a fracture. Our attention was drawn to the relationship between stress fracture and bone pain by three patients who were asymptomatic at the time that a bone scan revealed a stress fracture but who later developed pain at the site of abnormal uptake by bone. To answer this question we analysed retrospectively the bone scans of 64 patients studied for stress fracture.
MATERIAL AND METHODS The medical charts and bone scans of 64 military recruits aged 18-21 (average age 19 years) were reviewed retrospectively in order to correlate bone pain and areas of increased uptake in bone scintigraphy. All complained of localized pain in the lower limbs during exercise. Patients with a history of injury to the bone were excluded. Bone scintigraphy was carried out 2-3 hours after the injection of 15-20 mCi of -cmintravenous methylene-diphosphonate (Tc-MDP). A digital, large field-of-view gamma camera with a high resolution Dr Groshar is recipient of a fellowship from the International Atomic Energy Agency (Vienna), supported by the Brazilian Nuclear Energy Commission and the Atomic Energy Commission of Israel.
of Technology,
Haifa, Israel
collimator (Apex, Elscint Inc., Israel) was used to obtain 500 000 counts’ images of the pelvis and 300 000 counts of the lower limbs in the anterior view. When required, lateral, medial and posterior views were added. RESULTS A localized, well-defined, spindle-shaped, intense abnormal uptake was considered to indicate a stress fracture (Roub et al., 1979; Holder, 1982; Rosen et al., 1982). Diffuse, ill-defined areas of increased uptake were not so considered. The sites of abnormal uptake in the scintigrams were compared with the regions of localized pain. One hundred and twenty-four sites of stress fractures in the lower limbs were found in the 64 patients; 32 (26 per cent) caused no symptoms (Table I); in 38 patients (59 per cent) there were multiple sites of stress fractures, 32 (33 per cent) of these were asymptomatic (Table II). Twenty-six patients had a single symptomatic stress fracture. In three patients pain appeared in a previously asymptomatic site 7-14 days after the bone scan. These cases are now described. Tab/e 1. Distribution of sites with increased uptake and bone pain in 64 military recruits with stress fractures
Region of fracture Femur Proximal Medial Distal Total Tibia Proximal Medial Distal Total Fibula Medial Distal Total Tarsal bones Metatarsal bones Total
Abnormal Abnormal scintigraph y scintigraphy with pain without pain
3 11
8
Total
11 11
1: (47%)
179(53%)
Z (100%)
7 53
3 11
10 64
6: (83%)
14 (17%)
8: (100%)
1 3 (100%) 2 (100%) 3 (75%) 92 (74%)
1 0 ; (25%)
3 (100%) 2 (100%) 4 (100%)
32 (26%)
124 (100%)
Groshar et al.: Stress fractures and bone pain
527
Tab/e II. Distribution of sites with increased 38 subjects with multiple stress fractures Tibia Femur Pain Increased focal uptake
51 65
Fibula
10 27
CASE REPORTS An l&year-old military recruit was investigated after 4 weeks of training because he had pain in both feet during exercise. Bone scintigraphy showed increased uptake in the middle thirds of both tibias (Fig. 1). No abnormal uptake was seen in his feet. He was instructed to avoid exercise. One week later pain and tenderness came on in the middle third of his left tibia where the bone scan was positive.
Case 2 An l&year-old military recruit complained of pain in the distal third of his left tibia 6 weeks after he began training. Bone scintigraphy revealed abnormal uptake in the distal third of the left tibia and in the distal third of the right femur. The patient continued training, though less vigorously. Two weeks later during exercise he felt pain in the distal third of his right femur, at the site which previously showed abnormal uptake. Case 3 weeks after starting his training an l&year-old military recruit was investigated for pain in the dorsal aspect of the left foot during exercise. Scintigraphy showed increased uptake in the right first metatarsal bone and the lateral condyle of the left tibia. Physical activity was reduced. Ten days later he complained of pain in the left knee, with tenderness on the lateral aspect of the uppermost third of the left tibia, at the site which previously showed abnormal uptake. Three
result
and bone pain in
Tarsus Metatarsus
2 2
1 1
2 3
Total 66 98
that causes absorption of bone in excess of repair and bone formation in certain regions (Not-fray et al., 1980). The continual stress on the weakened bone leads to cortical and trabecular disruption, and subsequently to a fracture (Wilcox et al., 1977; Meurman and Eleving, 1980; Norfray et al., 1980; Granary et al., 1983). The typical clinical feature is the onset of pain during physical activity; this worsens if the activity continues and is relieved by rest. The early recognition of a stress fracture is essential in order to avoid severe injury to the bone. Radiography is much less sensitive than bone scanning for diagnosis of stress fracture (Geslien et al., 1976; Meurman and Eleving, 1980; Granary et al., 1983). Only 28 per cent of the cases will be positive in the early stages and as many as 50 per cent will be missed by radiography, even several weeks after the appearance of symptoms or after a positive bone scan (Granary et al., 1983). Many studies demonstrate the usefulness of bone scanning in the early diagnosis of stress fractures, with a reported sensitivity of 100 per cent (Roub et al., 1979; Belkin, 1980; Granary et al., 1983). Bone scintigraphy thus establishes the diagnosis in patients complaining of bone pain (Roub et al., 1979; Belkin, 1980; Holder, 1982; Granary et al., 1983). The three patients reported herein suggest the possibility that the abnormality on scintigraphy of bone may appear earlier than pain. Even when certain areas of abnormal uptake may be associated with pain, others may temporarily be painless. Asymptomatic stress fractures are more common in the femur than in the tibia; 53 per cent of the regions with abnormal uptake in the femur were painless, compared with 17 per cent in the tibia. The results of this study stress the necessity for scintigraphy of all susceptible bones in a population prone to stress fractures. While our material does not indicate the percentage of patients having stress fractures without pain in such a population, it does prove that there may be a delay between the onset of pain after the diagnosis has already been established by scintigraphy. We do not suggest that scintigraphy of bone should be done routinely in all military recruits or people starting on a jogging piogramme. It is our aim to draw attention to the fact that abnormal uptake indicating stress fracture may appear in the absence of pain, which will occur only later. The appearance of asymptomatic scintigraphic lesions is not confined to stress fractures and we have previously described this phenomenon in bone metastases (Front et al., 1979). activity
Case 1
DISCUSSION Stress fractures
uptake
from unusual,
repeated
physical
Fig. 1. ?cm-MDP bone scintigraphy of distal part of lower extremities. Two areas of abnormal, spindle-shape uptake in the middle third of both tibias are seen,
Acknowledgement We express our thanks to Dr Steven Baron for reviewing the manuscript.
528
REFERENCES Belkin S. C. (1980) Stress fractures in athletes. Orfhop. Clin. North Am. 11(4), 735. Daffner R. H., Martinez S. and Gehweiler J. A. (1982) Stress fractures in runners. JAMA 247, 1039. Front D., Schneck S. O., Frankel A. et al. (1979) Bone metastases and bone pain in breast cancer: are they closely associated? JAMA 242, 1747. Geslien G. E., Thrall J. H., Espinosa J. L. et al. (1976) Early detection of stress fractures using 99mTc-polyphosphate. Radiology 121, 683.
Granary R. B., Gerber F. H., Laughlin R. L. et al. (1983) Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology 146, 339. Holder L. E. (1982) Radionuclide bone-imaging in the evaluation of bone pain. J. Bone Joint Surg. 64A, 1391.
Injury: the British Journal of Accident Surgery (1985) Vol. 18/No. 8
Meurman K. 0. A. and Eleving S. (1980) Stress fracture in soldiers: a multifocal bone disorder. Radiology 134, 483. Norfray J. F., Schlachter L., Kernahan W. T. et al. (1980) Early confirmation of stress fractures in joggers. JAMA 243, 1647.
Rosen P. R., Micheli L. J. and Treves S. (1982) Early scintigraphic diagnosis of bone stress and fractures in athletic adolescents. Pediatrics 70, 11. Roub L. W., Gumerman L. W., Hanley E. N. et al. (1979) Bone stress: a radionuclide imaging perspective. Radiology 132, 431.
Wilcox J. R., Moniot A. L. and Green J. P. (1977) Bone scanning in the evaluation of exercise-related stress injuries. Radiology 123, 699. Paper accepted
I1 January 1985.
Requm for reprim should he uddwssed to: Dr D. Front, Department of Nuclear Medicine, Rambam Medical Center, Haifa 3.5254, Israel.