18 May How is a bone stress injury diagnosed?
Bone stress injuries (BSI) are an overuse injury, but how are they actually diagnosed? Diagnosis comes from understanding the present symptoms, a thorough history examination, physical examination and potential imaging.
What are common symptoms with a bone stress injury
The most common symptom associated with bone stress injury is pain. Initially, this can be typified as a vague ache and a gradual onset occurring with activity (weight-bearing/bone loading activity such as running, jumping etc). In the early stages the pain can quickly settle once the loading as been removed (rest). If activity continues, the pain does not go away.
As the injury progresses, pain can become more intense. This includes more sharp and localised pain on the bone with loading. In the more severe cases, pain will be felt even with low load activities (ie. walking) will lead to inflammatory symptoms, including pain at rest and night-time.
History examination for BSI
BSI do not occur without loading of the bone, so an understanding of a thorough training or activity history is essential. In particular, seeing what has changed in your training or exercise regime and there has been a significant increase in load (intensity or volume). It is also important to know if there has been a change in footwear or surface (particularly if training on a harder surface).
Past history of bone stress, fractures and family history should also be investigated. While in female athletes, it is essential to evaluate the female athlete triad- which is the interrelationship of menstrual dysfunction, low energy availability (restricted dietary behaviours) and low bone mineral density (BMD).
Medication history is required, as hormonal medications, oral contraceptives, steroids and antacids, can all impact your bone health.
What physical tests help diagnose bone stress injuries
On physical examination, one of the main tests is palpation. This is where a therapist is pressing over the bone and looking to reproduce localised tenderness. In sites where the bones cannot be directly palpated, then using specific bone loading tests is performed (including single leg hop).
Other tests that have been suggested for diagnosis include tuning forks and therapeutic ultrasound pain induction. However the scientific evidence for these tests is not strong. In particular tuning forks can produce a lot a lot of false positives (ie. it is positive in people without bone stress injury) and negative tests do not actually help rule out BSI.
Imaging for BSI
Imaging can be useful in diagnosis of BSI. The gold standard imaging for diagnosing bone stress injury is Magnetic Resonance Imaging (MRI). This is more sensitive and specific in detecting BSI compared with standard X-rays. In fact often X-rays will appear normal in appearance especially in the early stages of BSI.
However this does not mean every BSI needs to be imaged. Your physiotherapist or healthcare practitioner will determine if imaging is necessary and this based on:
- Will imaging change your management?
- Do the benefits of imaging outweigh the risks and costs
- Will imaging help with staging and prognosis?
- Is the bone stress injury at a high risk site?
- High risk bone stress injuries sties include:
- Femoral neck
- Anterior cortex of the tibia
- Medial malleolus
- Taus (lateral process)
- Navicular
- Proximal diaphysis of the 5th metatarsal
- Base of 2nd metatarsal
- Sesamoid bone of the foot
- High risk bone stress injuries sties include:
Therapists may utilise the below algorithm to determine if imaging is required:
Jessica Bank
Physiotherapist
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References
Matheson, G. O., Clement, D. B., McKenzie, D. C., Taunton, J. E., Lloyd-Smith, D. R., & MacIntyre, J. G. (1987, Jan-Feb). Stress fractures in athletes. A study of 320 cases. Am J Sports Med, 15(1), 46-58. https://doi.org/10.1177/036354658701500107
Mugunthan, K., Doust, J., Kurz, B., & Glasziou, P. (2014, Aug 4). Is there sufficient evidence for tuning fork tests in diagnosing fractures? A systematic review. BMJ Open, 4(8), e005238. https://doi.org/10.1136/bmjopen-2014-005238
Schneiders, A. G., Sullivan, S. J., Hendrick, P. A., Hones, B. D., McMaster, A. R., Sugden, B. A., & Tomlinson, C. (2012, Sep). The ability of clinical tests to diagnose stress fractures: a systematic review and meta-analysis. J Orthop Sports Phys Ther, 42(9), 760-771. https://doi.org/10.2519/jospt.2012.4000
Wright, A. A., Taylor, J. B., Ford, K. R., Siska, L., & Smoliga, J. M. (2015, Dec). Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis. Br J Sports Med, 49(23), 1517-1523. https://doi.org/10.1136/bjsports-2015-094828