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Fatigue Bone Stress Injuries of the Lower Extremities in Finnish Conscripts

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Fatigue Bone Stress Injuries of the Lower Extremities in Finnish Conscripts From the Department of Radiology, University of Helsinki; and the Research Institute of Military Medicine, Central Military Hospital, Helsinki Fatigue bone stress injuries of the lower extremities in Finnish conscripts Maria Niva Academic dissertation To be presented, with the assent of the Faculty of Medicine of the University of Helsinki, for public discussion in Small hall of the University main building on February 10th, 2006 at 12 noon. Helsinki 2006 Supervised by Docent Harri Pihlajamäki, M.D., Ph.D. Department of Surgery and Research Institute of Military Medicine Central Military Hospital Helsinki, Finland and Docent Martti Kiuru, M.D., Ph.D, MSc. Department of Radiology Helsinki University Helsinki, Finland Reviewed by Docent Jari Parkkari, M.D., Ph.D. Tampere University Tampere, Finland and Docent Riitta Parkkola, M.D., Ph.D. Department of Radiology Turku University Turku, Finland To be discussed with Docent Osmo Tervonen, M.D., Ph.D. Department of Radiology Oulu University Oulu, Finland ISBN 952-91-9857-4 (nid.) ISBN 952-10-2923-4 (PDF) Press: Yliopistopaino, Helsinki 2006 To all who are interested in bone stress injuries Contents ABSTRACT ................................................................................................6 LIST OF ORIGINAL PUBLICATIONS ..........................................................8 ABBREVIATIONS ......................................................................................9 1. INTRODUCTION ...................................................................................10 2. REVIEW OF THE LITERATURE ..............................................................12 2.1. Historical aspects of bone stress injuries ...................................12 2.2. Terminology of bone stress injuries ...........................................13 2.3. Bone marrow, epiphyses, metaphyses .......................................16 2.4. Bone reaction to stress ...............................................................18 2.5. Incidence of bone stress injuries ................................................20 2.6. Etiology of bone stress injuries ..................................................20 2.7. Clinical diagnosis of bone stress injuries ...................................22 2.8. Diagnostic imaging of bone stress injuries ................................23 2.8.1. Radiography ........................................................................23 2.8.2. Scintigraphy .........................................................................23 2.8.3. Magnetic Resonance Imaging ............................................24 2.9. Differential diagnosis of bone stress injuries ............................25 2.10. Asymptomatic bone stress injuries ...........................................28 2.11. Symptomatic bone stress injuries .............................................28 2.12. Bone stress injuries in the lower extremity .............................29 2.12.1. Bone stress injuries of the hip ..........................................30 2.12.2. Bone stress injuries of the femoral shaft .........................30 2.12.3. Bone stress injuries of the knee .......................................31 2.12.4. Bone stress injuries of the ankle and foot .......................32 3. AIMS OF THE PRESENT STUDY ..........................................................35 4 4. MATERIALS AND METHODS ..............................................................36 4.1. Patients ........................................................................................36 4.2. Clinical diagnosis .........................................................................39 4.3. Imaging methods .......................................................................39 4.3.1. Pelvis and hip ......................................................................40 4.3.2. Knee .....................................................................................40 4.3.3. Ankle and foot ....................................................................40 4.4. Image interpretation ..................................................................41 4.5. Statistical methods ......................................................................41 5. RESULTS ...............................................................................................44 5.1. The occurrence and clinical signifi cance of asymptomatic bone stress injuries in elite recruits (I) ..............................................44 5.2. The incidence, location, and nature of bone stress injuries in the knee (II) ....................................................................................44 5.3. The incidence, location, and nature of bone stress injuries in the femoral bone (III) ....................................................................48 5.4. The incidence, location, and nature of bone stress injuries in the ankle and foot (IV) ..................................................................54 6. DISCUSSION .........................................................................................63 6.1. Patients and study design ...........................................................63 6.2. The occurrence and clinical signifi cance of asymptomatic bone stress injuries .............................................................................63 6.3. Incidence of bone stress injuries ................................................64 6.4. Location and nature of bone stress injuries ..............................65 6.5. Imaging of bone stress injuries ..................................................67 7. CONCLUSIONS .....................................................................................68 8. SUMMARY ...........................................................................................70 9. ACKNOWLEDGEMENTS ......................................................................73 10. REFERENCES ......................................................................................75 ORIGINAL PUBLICATIONS .......................................................................84 5 Abstract Bone stress injuries resulting from overuse are frequent not only in ath- letes and in military trainees but also among healthy people who have recently started a new or intensive physical activity. Diagnosis of bone stress injury is based on the patient’s history of increased physical activity and on imaging fi ndings. In the prospective study I, the occurrence and the clinical signifi cance of asymptomatic bone stress injuries in elite-unit military recruits un- dergoing intensive physical training in the Parachute School of the Utti Jaeger Regiment was examined by clinical and MRI follow-up before commencement of the intensive training period, at 6 weeks from com- mencement, and on completion of the 5-month training program. In the retrospective studies II-IV, the incidence, location, nature, and patterns of bone stress injuries in the knee, the femoral bone, and the ankle and foot were examined based on MRI. In all studies I-IV, the MR images with bone stress injury fi ndings were evaluated with respect to bone stress injury location and bone stress injury type, and bone stress injuries were graded. The results of the study I indicate that 16 of a total of 21 recruits dis- played altogether 75 bone stress injuries on three MRI scans. Only 40% of the bone stress injuries were symptomatic. Symptoms depended on the location and MRI grade of injury, with higher grades usually more symptomatic. Repeated clinical and MRI assessment indicated that 84% of asymptomatic grade I bone stress injuries healed or remained as grade I and asymptomatic. In the study II, the incidence of bone stress injuries in the knee was 103 per 100,000 person-years (88 patients with a positive MR fi nding out of 85,318 conscript-years, 141 bone stress injuries, a total of 1330 pa- tients MR imaged). Bilateral bone stress injuries of the knee were found in 25%, and two solitary bone stress injuries in the same knee simultane- ously in 28% of the patients. The most common anatomic location was the medial tibial plateau, which was also the most typical location for a more advanced injury. After the commencement of the military service, 6 a bone stress injury in the medial tibial plateau caused knee pain earlier than a bone stress injury elsewhere in the knee (p=0.014). In the study III, the incidence of femoral bone stress injuries was 199 per 100,000 person-years (170 patients with a positive MR fi nding out of 85,318 conscript-years, 185 bone stress injuries, a total of 1857 patients MR imaged). The three most common sites were the neck (50%), the con- dylar area (24%), and the proximal shaft (18%). A stress reaction occurred in 57%, and a fracture line in 22% of the cases. There was a statistical correlation between the bone stress injury grade and the duration of pain (p=0.001). Bone stress injuries in the upper femur showed a shorter dura- tion of pain than bone stress injuries in the condylar area of the knee. In the study IV, the incidence of bone stress injuries in the ankle and foot was 126 per 100,000 person-years (131 patients with a positive MR fi nding out of 104,340 conscript-years, 378 bone stress injuries, a total of 267 patients MR imaged). 58% of the injuries occurred in the tarsal bones and 36% in the metatarsal bones. Multiple bone stress injuries in one foot occurred in 63% of the cases. In tarsal bones except the calcaneus and in metatarsal bones except the fi fth metatarsal bone, a bone stress injury was signifi
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