Fredericson grading demonstrated 26 grade 0, 19 grade I, 80 grade II, 29 grade III, and 5 grade IV. MRI was positive in 84% (133 of 159) of tibiae evaluated. One patient opted only to evaluate 1 leg. A total of 159 tibiae underwent evaluation. Linear regression analysis was also performed to determine the optimal combination of clinical examinations using SAS 29 (Version 9.4 2013).Įighty athletic adolescents participating in multiple sports including cross-country, track and field, soccer, lacrosse, and basketball volunteered for this institutional review board–approved study (52 girls, 28 boys age 14-18 years). Results of clinical examination underwent statistical analysis to determine sensitivity, specificity, PPV, and NPV. MRI was reviewed by an experienced independent musculoskeletal radiologist who graded BSI utilizing a 4-grade grading scale described by Fredericson et al 8: grade I-periosteal edema on T2 images, grade II-marrow edema on T2, grade III-marrow edema moderate to severe on T1 and T2 images, and grade IV-severe marrow edema with visible cortical fracture line on T1 and T2 images. Prior to the beginning of the study, each physician was instructed on how to perform each examination. On completion of the physical examination, routine radiographs and MRI of both tibiae were obtained on the same day as the examination. Examination was performed by 1 of 4 sports medicine fellowship–trained orthopaedic surgeons who recorded the results of the clinical examination prior to completion of MRI. ![]() After consent was obtained, a history and physical examination was performed on 80 high school athletes with >1-week history of shin pain. In total, 80 patients were enrolled in this study. Patients who demonstrated numbness, radiating pain into the foot, or symptoms suggestive of a compartment syndrome, compression neuropathy, or other neurovascular injury were excluded from the study. Athletes who were >19 years and who reported a traumatic event with no preexisting symptoms were excluded from this study. Patients presenting to an orthopaedic practice with a chief complaint of sports-related, atraumatic shin pain were considered for participation in this institutional review board–approved study. Our hypothesis is that the accuracy of clinical examinations or combination of examinations is comparable with the MRI diagnosis of BSI. The other specific aim is to compare these clinical tests and combinations of them with the grade of BSI determined by MRI. A specific aim of this study is to evaluate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for various clinical tests for diagnosis of tibial BSI by describing 5 commonly utilized clinical tests. 30 Consequently, clinicians often rely on results of imaging to make a definitive diagnosis of BSI and determine appropriate prognosis for return to sports. ![]() Therefore, the ability of clinical tests to diagnose a BSI early is of significant clinical benefit.ĭescription and validation of clinical examinations is lacking in existing literature. 30, 33 Ohta-Fukushima et al 22 found significantly better outcomes for patients with BSI diagnosed within 3 weeks of the initiation of symptoms versus those diagnosed later. This makes the clinician’s clinical assessment important, as making an early diagnosis of BSI has been shown to result in improved outcomes. Patients are often symptomatic long before radiographic identifiable fracture occurs. Consequently, to reduce confusion among clinicians, we advocate for the use of the term BSI, which is an all-encompassing term first utilized by Markey 16 and used to describe a range of bone injury from periostitis, stress reaction, and marrow edema to complete stress fracture, which demonstrates a frank cortical fracture. With the advent of magnetic resonance injury (MRI), stress-related tibial pain can be visualized as a spectrum of injury. 1 Common terminology used by clinicians includes stress fracture, shin splints, medial tibial stress syndrome, and stress reaction. Consequently, there is confusion among clinicians, and there are various nomenclatures utilized in the literature to describe lower leg pain in athletes. 18, 23, 32 Clinically, the cause of lower leg pain can be difficult to diagnose and troublesome to manage because of the wide range of potential diagnoses, 9, 25 including BSI, exertional compartment syndrome, muscular, neurologic, and vascular injury. As many as 84% of these athletes identify as having bone stress injury (BSI), 21, 24, 35 with the most frequently reported site being the tibia. ![]() Lower leg pain is a common 1 presenting complaint among adolescent athletes.
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