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First Study to Present Evidence on Tests for Stress Fractures
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Posted on: 10/17/2012
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Physical therapists from New Zealand may be the first to conduct a meta-analysis of tests used to diagnose stress fractures of the leg. The specific tests used to assess patients for stress fractures include the use of a tuning fork, X-rays, ultrasound, and other more advanced imaging studies such as bone scans and MRIs.
A stress fracture is a hairline crack in the bone that can grow larger over time if not treated properly. There are two types of stress fractures. Insufficiency fractures are breaks in abnormal bone under normal force.
Fatigue fractures are breaks in normal bone that has been put under extreme force. Fatigue fractures are usually caused by new, strenuous, very repetitive activities, such as marching, jumping, or distance running. Fatigue type of stress fractures are the main focus of this analysis.
Stress fractures were once most common among military personnel who marched and ran day after day. But today, stress fractures are on the rise in athletes, from distance runners and sprinters to skaters, hurdlers, and tennis, volleyball, soccer, and basketball players. Dancers and gymnasts are not immune either. Men and women in these two sports who train more than five hours a day have been shown to be 16 times more likely to develop a stress fracture.
MRIs or bone scans are the most sensitive and accurate tests for bone pathology. But these are expensive and aren't always available. Finding a reliable and practical test that a physical therapist can use in a clinical setting would be a useful tool. To investigate which tests are the best, the authors reviewed every article on stress fracture testing. They confined the articles to those on stress fractures of the lower extremity over the past 50 years (from 1950 to 2011).
Here's what they discovered: 1) the use of therapeutic ultrasound to diagnose stress fractures is not enough by itself. Pain can be reproduced by applying ultrasound over the fracture site occurs as a result of heat produced at the fracture site. But as studies show, the results are too imprecise to be depended on for diagnosis.
2) The use of a tuning fork to create vibration that reproduces the pain is problematic. Different forks have different frequencies. Studies have not been done to establish any kind of standard or reference for normal versus abnormal. The overall accuracy of this test in diagnosing a bone fracture just isn't good enough at this time. More high-quality studies are needed to clarify the role of tuning fork vibrations in identifying stress reactions of the bone.
3) The evidence to date suggests that radiologic imaging is still the best way to confirm the true presence of a stress fracture in the bone. Early detection is important to avoid further injury and long delays in rehabilitation and return to sports for competitive athletes.
For now, there is no clinically proven test that can be applied by the physical therapist to determine conclusively the presence of a stress fracture. Local tenderness over the bone in question, pain with weight-bearing or load through the leg, and a thickening or swelling over the bone suggest the need for further evaluation with imaging studies.
Although this study did not address which imaging study is the best, other research has shown that bone scans (called scintigraphy) and MRIs are the most accurate test procedures. MRIs give better details of the anatomy and they are not invasive but they are more expensive compared with scintigraphy. Not all communities have medical facilities that offer this type of advanced imaging. Future studies to find a reliable and accurate clinical test that doesn't require expensive radiologic testing would be very helpful.
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References:
Anthony G. Schneiders, PT, PhD, et al. The Ability of Clinical Tests to Diagnose Stress Fractures: A Systematic Review and Meta-Analysis. In Journal of Orthopaedic & Sports Physical Therapy. September 2012. Vol. 42. No. 9. Pp. 760-771.
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