Aaron Welk DC, DACBR / Chiropractic Radiologist with Gateway Radiology Consultants
Guest Contributor
Patient History:
13-year-old female soccer player with progressively painful limp of approximately 6 weeks duration. The father (also the team coach) presented to the clinic to purchase tape to treat his daughter's "classic calf tear." The parent agreed to allow his daughter to be evaluated for evidence of a strain injury.
Physical examination revealed 5/5 muscle strength with plantar flexion and dorsiflexion. The patient could tolerate toe walking with minimal discomfort. Pain was reproduced with single leg hop and with running. Focal discomfort was elicited with deep palpation of the calf musculature.
Sonography of the leg was performed to exclude strain injury.
Images:
Imaging Findings:
The medial and lateral gastrocnemius soleus junctions were intact. There was normal echotecture of the musculature of the superficial and deep compartments of the leg. No focal periosteal reaction was identified.
Following the negative sonographic examination, the patient was referred for radiographic imaging.
Images:
Imaging Findings:
AP and lateral projections of the leg demonstrated a hazy transverse sclerotic band within the medullary portions of the proximal tibial diaphysis, consistent with stress reaction. There was minimal periosteal stress reaction adjacent to the medullary sclerosis. No soft tissue edema was identified.
Diagnosis:
Tibial stress fracture
Discussion:
Stress injury can be classified as fatigue fracture (abnormal stress on normal bone) or insufficiency fracture (normal stress on abnormal bone). The clinical presentation of the bony stress reaction is varied. Localized pain with activity is most common, but stress fractures in deeper anatomic sites may be vague in their clinical presentation. Patients often have a history of new or increased physical activity. The lower extremity is much more commonly involved than the upper extremity. Common sites of involvement include: the 2-4th metatarsals, base of the 5th metatarsal, posterior calcaneus, talar neck, and navicular. The long bones of the lower extremity may also be involved, but less commonly.
Radiography is somewhat insensitive for detection of early stress injury. Bony sclerosis, cortical thickening, and periosteal reaction are the typical findings in stress injury.
Ultrasound may also be used to detect stress injury, but is also insensitive for detection of early injury. Periosteal reaction must be present for stress injury to be detectable with sonography.
Magnetic resonance imaging is very sensitive for detecting early stress injury. Bone marrow edema within the medullary cavity is seen prior to the development of cortical thickening and periosteal reaction.
Bone scan may also be used for early stress reaction detection.
Treatment depends on the anatomic site of the stress reaction. Non-weight bearing and activity modification until pain subsides is the most common treatment. Orthopedic consultation may be warranted for more advanced stress injury.
References:
Yochum TR, Rowe LJ. Yochum and Rowe's Essential of Skeletal Radiology. 3rd ed. Baltimore (MD): Lippincott Williams & Wilkins; 2005. p. 921-927.
Radiopaedia.org
Dr. Aaron Welk is a 2009 graduate of Logan College of Chiropractic. He went on to complete an additional 4.5 years of Residency and Fellowship training in the Logan University Department of Radiology, earning Board Certification in Chiropractic Radiology in 2013. He is also certified as a Chiropractic Physician. Through the course of his radiology training he enjoyed the opportunity to examine patients ranging from “Weekend Warriors” to All-Star professional athletes.
Visit his website for more information.