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Continuing Education

Clinical applications of nuclear medicine in the diagnosis and

evaluation of musculoskeletal sports injuries夽
Montse Minoves Font a,b,∗
a
Cetir-Ascires, Barcelona, Spain
b
Vocal del Grupo de Patología Musculo-Esquelética de la SEMNIM, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Increased participation in sports and physical exercise are widely promoted as an approach to a physically
Received 18 July 2019 active lifestyle which has a positive effect on healthy aging, in patients and athletes of all ages, begin-
Accepted 21 September 2019 ners and experts, including amateur athletes and professional athletes. Unfortunately, this has caused
Available online xxx
a higher incidence of sports-related injuries. In the sports context, the early and accurate diagnosis of
injuries is of the utmost importance in order to enable early treatment to achieve a full recovery. Imag-
Keywords: ing techniques are increasingly important for the successful diagnosis and management of the patient.
Impingement syndrome
The nuclear medicine techniques with bone tracers provide physiological and metabolic information in
Myositis ossificans
Osteochondral lesions
the early phases of musculoskeletal injuries, which often precede anatomical changes and they reflect
Sports injuries changes in bone turnover. This allows early diagnosis, along with evaluation of the activity and phase of
Hybrid imaging the injury. In this article, the applications of nuclear medicine techniques, focusing on bone scintigraphy,
Enthesopathies alongside the important contribution of hybrid studies (SPECT/CT), in the diagnosis of bone and soft tissue
Bone scintigraphy sports injuries, will be described. In addition, we explain their usefulness in the expression of the patho-
Stress fractures physiology of these lesions and their scintigraphic patterns. The article will also describe biomechanical
Spondylolysis and physiopathological aspects, injury mechanisms and clinical presentations of bone and joint sports
SPECT/CT
injuries, knowledge of this is essential for the correct diagnostic assessment of imaging studies.
© 2019 Sociedad
Española de Medicina Nuclear e Imagen Molecular. Published by Elsevier España, S.L.U. All rights reserved.

Aplicaciones clínicas de la medicina nuclear en el diagnóstico y evaluación de

las lesiones deportivas musculoesqueléticas

r e s u m e n

Palabras clave: El aumento de la participación en la práctica de deporte y actividad física promovido ampliamente por el
Síndromes de pinzamiento articular enfoque hacia un estilo de vida físicamente activo, con efecto positivo para un envejecimiento saludable,
Miositis osificante tanto en pacientes como en atletas de todas las edades, principiantes y expertos, en el deportista afi-
Lesiones osteocondrales
cionado y en el profesional, ha causado una mayor incidencia de las lesiones relacionadas con el deporte.
Lesión deportiva
El diagnóstico precoz y preciso de la lesión que permita iniciar precozmente el tratamiento adecuado,
Imagen hibrida
Entesopatias para conseguir la recuperación completa es fundamental en el contexto deportivo, siendo las técnicas
Gammagrafia ósea de imagen cada vez más importantes para el éxito diagnóstico y manejo del paciente. Las técnicas de
Fractura de estrés medicina nuclear con trazadores óseos proporcionan información fisiológica y metabólica en las fases
Espondilólisis precoces de la lesión osteoarticular, precediendo a menudo a los cambios anatómicos y reflejan los cam-
SPECT/TC bios en el recambio óseo, permitiendo el diagnóstico precoz y la valoración de la actividad y fase evolutiva
de la lesión. En el presente artículo, se describirán las aplicaciones de la medicina nuclear, en particular
de la gammagrafía ósea, con el valor aportado por los estudios híbridos (SPECT/TC) en el diagnóstico y
evaluación de las distintas lesiones deportivas osteo-articulares y de tejidos blandos, su utilidad en la
expresión de la fisiopatología de estas lesiones y su apariencia gammagráfica. Asimismo se explicarán
aspectos biomecánicos y fisiopatológicos, los mecanismos lesionales y las presentaciones clínicas de
las lesiones deportivas musculoesqueléticas, cuyo conocimiento es esencial para la correcta valoración
diagnóstica de las imágenes.
© 2019 Sociedad Española de Medicina Nuclear e Imagen Molecular. Publicado por Elsevier España,
S.L.U. Todos los derechos reservados.

夽 Please cite this article as: Minoves Font M. Aplicaciones clínicas de la medicina nuclear en el diagnóstico y evaluación de las lesiones deportivas musculoesqueléticas.
Rev Esp Med Nucl Imagen Mol. 2019. https://doi.org/10.1016/j.remn.2019.09.008
∗ Corresponding author.
E-mail address: mminoves@cetir.es

2253-8089/© 2019 Sociedad Española de Medicina Nuclear e Imagen Molecular. Published by Elsevier España, S.L.U. All rights reserved.

REMNIE-1111; No. of Pages 22

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Introduction
There has been an increase in regular participation in sports and
physical activity among the population which has been widely pop-
ularized by the promotion of physically active lifestyles considered
to be beneficial to health and healthy aging in both patients and
athletes of all ages. This activity involves beginners and experts,
amateurs and professionals alike and is not without potential col-
lateral effects which may produce musculoskeletal injuries during
any athletic activity, leading to a greater incidence of lesions related
to sports and physical activity. On the other hand, this universal-
ization of sports in the population and the prolongation of the age
at which sports activities are carried out as well as, on occasions,
training not directed by professionals, has led to an increase in
osteoarticular injuries which were not previously produced in these
populational segments.
From elite athletes with important pressure to continue their
activity and return to competition within the shortest time possi-
ble, to amateur sportspersons with a wide spectrum of ages ranging
from those beginning sports late and even at advanced ages (some-
times for medical prescription), it is necessary to have imaging
techniques able to diagnosis and accurately evaluate lesions early
to achieve complete recovery. This is especially important in elite
athletes in order for them to return to their activity as soon as
possible and in optimal conditions and with maximum perfor-
mance, avoiding possible progression of a lesion or the appearance
of complications due to inadequate reincorporation to their sports
activity. Taking all of this into account, imaging techniques are
increasingly more important for diagnostic success, therapeutic
decision making and control of the evolution of a sports injury.
Another context different from that of a professional athlete but of
no less diagnostic importance is the case of “pediatric” and “geri-
atric” athletes in whom the diagnosis of some lesions may remain
obscure for some time. Sports physicians often need to distin-
guish between lesions requiring immobilization and rest and those
requiring physical therapy, rehabilitation or reparative surgery of
soft tissue lesions. To do this it is of great importance of make a diag-
nosis early and evaluate the specific extent of the injury in order to
foresee the possible evolution and shorten the recovery time.1–3
Diagnostic imaging techniques
Technological advances should respond to diagnostic needs, and
improvements in the quality of images allow better differentia-
tion of the different anatomical structures and their characteristics,
enabling the detection of smaller lesions, with good images being
the basis of correct diagnosis. There are numerous diagnostic imag-
ing techniques, and the choice of one modality or another depends
on the suspected pathology and should be based on knowledge
of the capacities and limitations of each technique together with
knowledge of the physiopathology of the changes which occur in
different pathological conditions.The imaging modalities used for
the diagnosis of musculoskeletal disease have been included in two
complementary types of exploration: morphological or anatomi-
cal studies, such as radiography, ultrasonography, computerized
tomography (CT) and magnetic resonance (MR). Morphological
studies fundamentally depend on structural bone changes, vari-
ations in the density and differences in tissue proton content while
functional studies correspond to nuclear medicine and depend on
physiological and metabolic bone changes which determine the
most initial phases of the lesion often before the appearance of
anatomical alterations. Most of the pathological processes affect-
ing the skeleton produce an increase in osteoblastic and osteoclastic
activity which leads to an increase in bone remodeling.
Nuclear medicine techniques with bone radiotracers (99m Tc-
bisphosphonates and 18 F-sodium fluoride) provide physiological
and metabolic information in early phases of a musculoskele-
tal sports injuries, often preceding anatomical or structural bone
changes. These techniques can provide a functional map of bone
remodeling which demonstrates dynamic alterations of the bone,
showing focal or multifocal pathology and enable early diagnosis
as well as assessment of the activity and the evolutive phase of the
lesion.
The introduction of hybrid systems such as single photon emis-
sion computerized tomography with CT (SPECT/CT) and positron
emission tomography with CT (PET/CT) combine the functional or
physiological information of the nuclear medicine techniques with
the morphological or anatomical information of the structural bone
changes of CT in a single study. This has represented a revolution
for diagnosis in nuclear medicine, increasing the sensitivity and
especially the specificity, and providing better anatomical resolu-
tion of the images and exact localization of osteoarticular lesions,
and thus, greater diagnostic certainty. The most recent appearance
of the PET/MR approach combines functional and morphological
information and that of diseases of soft tissues and the bone marrow
and is a promosing technique with the use of 18 F-sodium fluoride.
Nonetheless, there are few studies on this technique, especially
in the evaluation of complex anatomical structures and those of
small size and with associated soft tissue lesions as well as in well
selected patients with clinical findings and other non conclusive
imaging techniques. However, the impact of PET/MR on the cost-
effecctiveness of the management of patients should be determined
due to its elevated cost.4–6
Bone scintigraphy (BS) with bisphosphonates labeled with
99m Tc-pertecnetate is one of the most frequently used nuclear
medicine studies performed for obtaining images of the muscu-
loskeletal system. The role of BS in the diagnosis and evaluation
of bone disease is well established and has demonstrated clini-
cal utility due to its elevated sensitivity and diagnostic yield, high
availability, easy to perform studies and the possibiity of obtain-
ing images of the whole skeleton with a low level of irradiation
to the patient and low economic cost. In the field of trauma and
sports pathology, the diagnostic efficacy of 2- or 3-phase BS stud-
ies has been established and remains as the imaging technique of
choice and diagnostic mainstay in daily clinical practice.The use
of SPECT/CT studies is of significant added value, allowing exact
localization of the lesion with avid radiotracer uptake and pro-
viding functional information of the morphologically characterized
lesions in the CT. This increases diagnostic reliability, and the lesion
can be visually demonstrated to the clinican, and likewise, to the
athletes in order to convince them of the need for treatment. How-
ever, it should not be forgotten that nuclear medicine physicians
can improve the specificity of the images by knowledge of the
characteristic scintigraphic patterns of each clinical situation, and
for correct interpretation, it is essential to know the clinical his-
tory and the physiopathology of sports injuries and their lesional
mechanisms.2,7,8
On suspicion of infectious bone or articular complications, the
techniques most commonly used for localization of the infectious
process in the peripheral skeleton are a combination of 3-phase
BS and labeled white blood cell scintigraphy, with SPECT/CT distin-
guishing between bone and soft tissue infeciton. The most adequate
study for evaluation of infection in the axial skeleton is 18 F-FDG
PET/CT or the combination of 3-phase BS and study with gallium
citrate (67 Ga), although the use of the latter has declined in the last
years.9,10
Key point
The addition of hybrid images (SPECT/CT) to 2- or 3-phase planar BS
provides greater diagnostic safety, with the integration of functional
and morphological information of the lesion in the same study and
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reflecting the global status of the bone and allowing early diagnosis
and accurate evaluation of musculoskeletal sports injuries.
Physiopathological bases and biomechanical considerations
The musculoskeletal system is made up of bones, joints, lig-
aments, muscles and tendons and the architecture or form of
assembly varies according to age and body segment. Response ver-
sus traumatisms and stress are, therefore, the response of all these
structures, compromising not only the bone but also the muscu-
loskeletal system as a whole.
Sports lesions can be defined as tissue damage that occurs as a
result of participation in sports or exercise. Lesions within the con-
text of sports are the result of the application of forces that exceed
the capacity of resistence on the whole body or part of it and which
can be applied instantaneously or over a prolonged period of time.
Thus, based on the onset of the symptoms and the mechanism of
the lesion, sports lesions are generally classified as: acute lesions,
secondary to an acute and single traumatic event (macrotrauma);
overload lesions or lesions due tor excessive use of determined
articulations and muscular groups and correspond to lesions that
occur over time by repetitive microtraumatisms to tendons, bones
or other tissues of the musculoskeletal system, and lastly, lesions
which exclusively affect soft tissue which can be produced in the
two lesional situations described.
The type of sports injuries as well as their incidence and severity
are conditioned by a series of factors that include the type of sports
activity performed. The most common injuries are those occurring
during specific activities, and the factors involved include: intrinsic
factors of the athlete depending on the physical characteristics of
the athlete, age and sex of the individual, physical and psychological
preparation, constitutional adaptabiity for sports, and on the other
hand, conditions external to the sportsperson, such as the playing
field, footwear, atmospheric conditions, and environmental condi-
tions at the time of the lesion, among others. Likewise, the skill of
the sportsperson in relation to the sport in question is also impor-
tant. In this sense, it is interesting to note that in contact sports the
most severe injuries are produced in the first quarter of the total
duration of the game, while the last quarter is characterized by an
important number of lesions of scarce importance, conditioned, in
part, by player fatigue.3,11
Any traumatism, whether it be secondary to an acute or repet-
itive lesional mechanism leads to a series of stereotyped tissular
responses which are characteristic of tissular lesions. This series
of events, with biochemical and immunological changes in the
injured tissue favors the localization of bone radiotracers and may
be detected before the morphological changes and produce local-
ized hyperemia which is easily apparent in the blood flow and early
phase (vascular pool) of 3-phase BS. The basis of the clinical util-
ity of BS in sports-related disease is its ability to detect lesions in
basic skeletal structures such as bone, articulations, striate muscle
and musculotendinous or musculoskeletal unions by its capacity
to detect changes associated with bone remodeling and vascular-
ization of the bone early as well as anomalous deposits of calcium
phsophate such as heterotopical ossifications and calcifications of
soft tissues. The addition of a SPECT/CT study improves the diagnos-
tic accuracy and specificity, providing important anatomical data
for treatment planning.
Bone is a dynamic tissue that require stress for normal develop-
ment and changes its own biomechanical properties by remodeling.
In response to stress bone changes in shape, being able to under-
take elastic or plastic deformation. At low levels of stress the
bone deforms elastically, which means that it will return to its
original form during resting, when the stress ceases, without per-
manent damage. When the stress reaches a certain critical level that
exceeds the limit of bone elasticity, the bone plastically deforms,
3
and in this situation, even after the stress disappears, the bone
retains some changes in its shape because its microstructures have
been damaged. Each application of stress above the critical level
increases the damage and is manifested by microfractures in the
bone which can progress to fissures and the fracture of the cor-
tical osseous bone lamellae with frank cortical disruption. Along
life there is a continuous process of bone remodeling which has
a beneficial effect in the long term since it creates a bone struc-
ture that can optimally oppose the stress applied. According to the
phenomenon known as Wolff’s law (The area to which loading is
applied will be modifed by remodeling processes. When the body
is subject to physical stress, the bone remodels in order to effi-
ciently distribute the stress load), intermittent forces applied to
bone stimulate remodeling of its architecture to optimally resist
a new mechanical setting. From a biochemical and biomechani-
cal point of view, the bone tissue is maintained by a process of
balance between reabsorption and formation. Osteoclastic reab-
sorption is the initial response to the increase in stress. If the normal
stress to which a bone is subjected is eliminated, rapid osetoclas-
tic reabsorption would rapidly occur followed by a reduction in
osetoblastic activity, resulting in osteoporosis due to disuse. The
stress related to daily activities stimulates the remodeling process
which occurs at the level of the osteones in the cortical bone, that
is the basic unit of bone structure. The exact mechanism that acti-
vates this process is unknown, but it has been suggested that it
may be related to the development of microfractures. Alteration
in osteocyte/osteoclast balance leads to exaggerated activity of
the osteoclasts which produce favorable conditions for a fracture
to occur. Although microdamage is a physiological phenomenon,
it becomes pathological when its production relevantly exceeds
repair. If the triggering activity reduces, the damage produced can
be cured before the development of a true fracture, as occurs when
athletes automatically adjust their style in a race in response to
pain, preventing lesions produced in training periods which might
progress to a stress fracture.5,8,12
Technical aspects
Each scintigraphic study should be oriented by evaluating the
clinical history, and independently of whether a SPECT/CT study is
made afterwards, it is essential to insist upon the need to obtain
technically demanding images. Two- or 3-phase BS with blood
flow and vascular pool images is mandatory in the region of the
acute symptoms since it can provide information on blood flow
and the greater or lesser grade of vascularization of the zone stud-
ied, indicating the possible participation of adjacent soft tissues.
This information is useful for differential diagnosis of lesions which
might be observed in the bone phase, especially in the case of
inflammatory processes, infections, and fractures, and it is espe-
cially important to increase the diagnostic yield in the syndrome of
complex regional pain and to help define the age of the lesions and
their evolutive phase.12 Tomographic studies (SPECT or SPECT/CT)
should always be performed for correct evaluation of pathology
of the vertebral spine. In the study of small bone structures such
as the hands and feet and in children as well as in the evaluation
of the characteristics of the scintigraphic patterns in determined
benign osteoarticular patholgies, amplification of the image has
classically been carried out with the use of a pinhole collimator.
Hybrid images (SPECT/CT) are excellent for assessment and accu-
rate localization of the lesion in complex anatomical bone regions
and with possible multifocal bone pathologies as in the bones of
feet and hands. It is especially useful for the evaluation of patients
post surgery and those with osteosynthesis in any localization of
the skeleton. In relation to metallic material, SPECT/CT can accu-
rately locate the foci of increased metabolic bone activity and its
morphological characterization in the CT image.13–15
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Fig. 1. Fracture of the distal epiphysis of the right radius in a 42-year-old amateur athlete secondary to a fall with an outstreteched hand 10 days previously, with a normal
simple radiography of the right wrist (A). Planar bone scintigraphy —delayed bone image of wrists and hands (B) and early image (C)— and the SPECT/CT — selected coronal
(D), sagittal (E), axial slices (F) of corresponding CT and fusion SPECT/CT and 3D reconstruction (G)— showing increased linear uptake in the distal epiphysis of the right
radius with an increase in vascularization in the distal end of the radius in the early image (black arrow), coinciding with the line of sclerosis in the CT image (white arrow),
indicating the presence of an acute bone fracture with signs of reparative osteogenic activity.

Key point
Knowledge of the clinical data and the physiopathology of sports
injuries and their lesional mechanisms as well as the characteristic
scintigraphic patterns in each clinical situation is essential for correct
diagnosis. It is also essential to obtain technically demanding images
and to perform a 2- or 3-phase BS study of the region of acute symp-
toms, with a good image being the basis for correct diagnosis.
Clinical applications
Post-traumatic fracture
Fractures are the most frequent bone lesion and constitute com-
plete or incomplete interruption of the structural continuity of the
bone, of the cartilage or both and may be produced as a result of
acute direct or indirect traumatism. Most high impact lesions pro-
duce fractures, and in most adult patients with traumatism, the
clinical history and physical examination followed by an appro-
priate conventional radiology study are sufficient to establish the
diagnosis in most localizations. However, in some cases the initial
radiographies do not show conclusive findings which can only be
observed in later radiological studies. BS plays a critical role in these
cases of suspicion of occult bone fracture and is able to diagnosis
the suspected lesion early and evaluate possible complications of
the fracture. In patients with polytrauma and already diagnosed
fractures, BS provides supplementary information by the possibil-
ity of performing whole body studies and detecting possible non
suspected lesions which will allow complete assessment of all the
post-traumatic lesions.
The sequence of physiopathological processes induced by a frac-
ture and associated with it cure leads to the preferential localization
of bone radiotracers which can be visualized early after traumatism
and reflect the physiopathology of the bone repair which begins
within 24 h post-traumatism. During bone repair there is a stable
or regular increase in the uptake of the radiotracer which per-
siss throughout the bone remodeling process. The BS study shows
pathological images within a few hours after the traumatism. Up
to 95% of fractures can be detected in the first 24 h following trau-
matism in patients under 65 years of age. In older patients the
diagnosis may be delayed to 48 -72 h.16 Practically 100% of frac-
tures present a pathological BS within 72 h post-traumatism, and
thus, in principle, a normal BS in this period of time rules out a bone
lesion.
The scintigraphic appearance of fractures is directly related to
the stage of curation and is modified according to the size of the
fracture and the bone affected. In non complicated fractures with a
normal evolution, 3-phase BS findings can be differentiated into 3
stages, which can determine the phase of curation: the first or acute
phase which occurs during approximately the first 2–4 weeks after
the aggression and is characterized in the three phases of the study
by an area of increased diffuse activity in the fracture zone that is
more extensive than the line of morphological fracture; the second
stage or subacute phase is from weeks 8–12, showing maximum
uptake in the fracture represented as an active well defined line
which more accurately corresponds to the anatomical localization
of the line of the fracture; and the third stage or healing phase which
occurs in the following 4–24 months in which only the images in
the bone or delayed study phase are abnormal. This stage is char-
acterized by a gradual reduction in the activity in the site of the
fracture until reaching normality.14
Key point
Bone scintigraphy studies show pathological images within a few
hours after traumatism and reflect the physiopathology of bone repair
in the site of the fracture. Up to 95% of fractures can be diagnosed within
24 h after the traumatism in individuals less than 65 years of age, while
diagnosis in older patients may be delyed to up to 48−72 hours.
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Fig. 2. This figure illustrates the principal complications of carpal scaphoid fracture in two cases. (A) Pseudoarthrosis of right carpal scaphoid fracture which occurred 11
months previously secondary to a fall with an outstretched hand. The planar study shows an increase of uptake in the right scaphoid bone with slight focal hyperemia in
the early image (arrows). The images of the SPECT/CT study —selected coronal slices of CT and fusion SPECT/CT— showing an increase of osteogenic remodeling activity in
the site of the bone fracture and morphological signs of non union with separation of the bone fragments in the fracture site in the CT image (white arrow), confirming the
defect of consolidation with scintigraphic characteristics of hypertrophic or reactive pseudoarthrosis. (B) Avascular necrosis in the left carpal scaphoid bone of a 17-year-old
football player presenting a left carpal scaphoid fracture 5 months previously, with persistence of pain and a negative radiological study. The planar scintigraphy study of the
wrists and hands —early image, delayed bone image and selective image of the left carpal magnified with a pinhole collimator— showing an absence of radiotracer uptake in
the proximal two thirds of the scaphoid bone with a cold area in this zone (arrow), that represents the site of avascular osteonecrosis, and there are osteogenic remodeling
changes in the distal scaphoid segment.

Occult fractures
The main application of BS in post-traumatic fractures is for
the diagnosis of fractures which are difficult to visualize by radiol-
ogy in early studies or are even impossible to detect radiologically
whether this be due to their size or localization in complex anatom-
ical bone structures or structures with low bone density. These are
known as occult fractures. When there is high clinical suspicion
of a fracture, BS should be performed despite a negative simple
radiography result.
The most frequent occult fractures are carpal scaphoid fractures
and those of the femoral neck and nondisplaced intertrochanteric
fractures, especially in elderly patients and individuals with osteo-
porosis. Other localizations of occult fracture involve other carpal
bones, fracture of the distal radius (Fig. 1), the ribs, sternum and
shoulder fractures, fractures of the posterior elements of the verte-
brae and tarsal bone fractures, among which those of the calcaneus,
the tarsal scaphoid and tarsometatarsal fracture-dislocation or Lis-
franc fracture are of note.
The terms “bone contusion” or “occult intraosseous fracture”
describe occult fractures produced by direct traumatism to the
bone in which a radiology study is never abnormal and BS is patho-
logical. The underlying pathology is the trabecular bone lesion
which may be associated with edema and hemorrhage extending
to the bone marrow space but with a lack of continuity of the corti-
cal bone and with very small cortical disruptions. Scintigraphically,
bone contusion represents an increase of blood perfusion in the
angioscintigraphic phase with an increase in activity in the early
phase and increased focal uptake of the radiotracer in the bone
phase, often of subchondral localization.
Fractures localized in the neck of the femur may show more
delayed diagnostic images in BS than those of other localizations. It
is well described in the literature that there may be false negative
studies, especially in elderly patients and within 72 h of the tra-
muatism, and it has been suggested that these are probably due to
slower bone remodeling in this age group.16 Holder et al.17 reported
a sensitivity and specificity for BS for the detection of fractures of
the femoral neck of 93 and 95%, respectively, with a negative predic-
tive value of 96%. These fractures have a characteristic scintigraphic
appearance with increased linear uptake of the radiotracer in the
neck of the femur which can rule out other bone lesions. SPECT/CT is
of great use and provides a greater sensitivity for the early diagno-
sis of these fractures as well as for the detection of complications
such as avascular necrosis of the head of the femur secondary to
displaced fractures of the neck of the femur. In addition, SPECT/CT
enables correct diagnosis in cases described as false positive stud-
ies for fracture of the neck of the femur, such as the presence of
marginal collar osteophytes in the femoral neck and synovial her-
niation pit, and morphological images (CT) can clarify the cause of
uptake in the femoral neck.12,18
Rib fractures constitute one of the most frequent non visible
fractures in simple radiography even when there is clinical suspi-
cion, especially in fractures without displacement and those which
are localized adjacent to the costochondral junction. The risk of this
type of fracture is high in contact sports.
Fractures of the distal radius are frequent in sports and may be
accompanied by other lesions such as fractures of the carpal bone,
ligamentous lesions or lesions of the distal radioulnar articulation
or in the region of the elbow.
Fracture of the scaphoid carpal bone is one of the most frequent
occult fractures and is the most common fracture of the carpal bone
with a sensitivity of 60–70% for all carpal fractures. This fracture is
usually produced by an indirect mechanism secondary to a fall with
on an outstretched hand with the wrist in hyperextension and with
ulnar deviation. It can be reliably diagnosed by scintigraphy within
72 h of the traumatism and within 24 h in more than 95% of the
cases. Early detection is very important due to the tendency to non
union or consolidation if the fracture is not adequately immobi-
lized (Fig. 2). The sports with the greatest risk for fractures of the
scaphoid carpal bone include basketball, hockey, football, boxing,
cycling and skating.
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Triquetral fractures correspond to 14% of all carpal fractures and
are produced as a consequence of impact to the dorsal surface of the
triquetral bone against the ulnar styloid apophysis by a fall onto an
outstretched hand and with the wrist in ulnar deviation. Fractures
of the triquetral bone are rare and due to high impact energy.19
Fractures of the carpal bones can be problematic due to the high
incidence of the development of avascular necrosis in the proximal
two thirds of the scaphoids: proximal pole of the large bone and at
the base of the apophysis of the hamate bone. In the case of non
conclusive radiographical results in these fractures, a pathological
BS may alert the need to prescribe prolonged immobilization and
reevaluation of lesions which may require surgery.8,12
Fractures of the of the hamate bone are found in 0.5–2% of all
carpal fractures and are frequent in sports such as golf, baseball, and
in general, in racket sports as a consequence of direct traumatisms
on the surface of the palm of the hand by a racket, the grip or the
head of a golf club or a baseball bat.8
The Lisfranc lesion is of note among occult fractures of the tarsal
region since they may remain unnoticed in the initial evaluation
after foot traumatism. This lesion is primarily a disruption of soft
tissue of the ligamentous support of the joint which may include
fracture. It is prodced by impact on the toes of the foot causing dor-
sal or plantar dislocation with associated fracture, depending on the
direction of the impact. It is relatively uncommon and corresponds
to only 9% of all tarsometatarsal fractures. Delay in diagnosis leads
to deficient treatment which can lead to an abnormal articulation
with chronic pain. In many of these patients the fracture is not
initially detected in the simple radiography study and is later sus-
pected by the persistence of pain of potentially osseous origin. BS,
especially with the addition of a SPECT/CT study, is of great value for
the diagnosis and detection of this fracture and for the localization
of possible associated fractures. The scintigraphic image is char-
acteristic, with a linear band of increased uptake which extends
through the tarsometatarsal articulations.14
Key point
In post-traumatic fractures the main application of BS is for the
diagnosis of occult bone fractures. SPECT/CT is of great value for early
diagnosis of fractures of the neck of the femur and allows accurate
localization of occult fractures in carpal and tarsal bones, being of spe-
cial utility for the detection of possible associated fractures in Lisfranc
lesions.
Complications in the healing of fractures. Pathology of
consolidation
The healing process of a fracture and the time needed for this
may be affected by many clinical variables. The possibility of eval-
uating if the healing of a fracture is progressing normally or if there
are complications in fracture consolidation is another of the appli-
cations of nuclear medicine techniques in traumatic injuries and
sports diseases. The time of scintigraphic normalization is greater
than than of clinical and radiological cure due to the persistence of
bone remodeling phenomenon which are necessary to completely
restore the mechanical strength of the affected bones, but the local-
ization of the fracture and the age of the patient also influence. In
general it is accepted that 90% of noncomplicated fractures show
evidenve of healing at one year and at 2 years almost all normally
healed fractures present a normal BS.
The diagnosis of non consolidation or non union or pseu-
doarthrosis is not justified until there is clinical or radiological
evidence that healing has stopped and consolidation is extremely
unlikely. This situation may be defined as failure in healing when
more than 6–8 months have gone by after the traumatism and
occurs in approximately 5% of fractures. Predisposing factors
include: open fractures, comminuted fractures, displacement and
separation of bone fragments, overlapping of soft tissue between
the two, immobilization failure with poor contact of the ends of the
fracture or excessive movement in the line of the fracture, insuf-
ficient immobilization time, incorrecct orthopedic reductions and
physiological factors which can increase the possibiity of non union
and include infection, inadequate blood flow, poor nutritional sta-
tus, osteoporosis and metabolic diseases.8,16 Assessment of fracture
healing and its classification as union failure which is generally
based on clinical signs and symptoms together with radiological
findings do not provide sufficient information on local vascular-
ization and the capacity of bone response. These factors can be
evaluated by BS. When the scintigraphic study shows persistently
greater than normal radiotracer uptake in the post-fracture period
without a reduction in the activity of the fracture site after 4–6
months, the presence of an alteration in consolidation should be
suspected (delayed consolidation, pseudoarthrosis).
Non union of fractures can be radiologically differentiated
according to their morphology as hypertrophic, oligotrophic, com-
minuted and with bone defect or artrophic, based, in part, on the
specific pathogenesis of non union. The radiologic study is a com-
mon indicator of the quality of bone callus, but the metabolic
information provided by BS in each type of non union fracture
site is important for posterior therapeutic decisions, including the
determination of the utility of electric stimulaton.12,20 Two types
of non consolidation or pseudoarthrosis can be distinguished by
scintigraphy according to the metabolic activity in the site of the
fracture. One is reactive or hypertrophic non consolidation which is
found in both the early and the delayed phase as diffuse and per-
sistent increased uptake of the radiotracer indicating that the ends
of the bone are hypervascular and hypertrophic and able to bio-
logically react. The second type of non consolidation is atrophic
non consolidation in which global increased uptake of the radio-
tracer is observed in the site of the fracture or there is a central
cold band between the ends of the bone with increased uptake that
reflects the inability of the ends to respond to the healing process.
The addition of a SPECT/CT study can identify and localize whether
the osteogenic response in the site of the fracture with exaggerated
or reduced or absent union defect affects both ends of the bone or
only one8,12,14 (Fig. 3). In cases of suspected infectious bone or artic-
ular complications, the utility of the combination of BS with more
adequate infection/inflammation studies with radiotracers accord-
ing to the localization of the infectious process in the peripheral or
axial skeleton has already been described.
In addition, BS is a simple method of follow-up to evaluate
whether there are other post-fracture complications such as avas-
cular necrosis, sympathetic-reflex dystrophy or post-traumatic
arthropathies.
Key point
The use of BS in addition to a SPECT/CT study provides information
related to local vascularization, the capacity of bone response and the
morphology of the ends of the bone in the site of the fracture. Two types
of non consolidation or pseudoarthrosis can be differentiated according
to metabolic bone activity in the fracture: reactive or hypertrophic
and artophic. Distinction between the two is important for posterior
therapeutic decision making.
Post-traumatic inflammatory arthropathy
Post-traumatic arthritis or synovitis is synovial and bone
response to traumatism and may be the cause of the persistence
of pain and limited mobility despite normal radiographic findings.
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Fig. 3. Stress fracture of the fifth metatarsal bone of the left foot which occurred 2 years previously with a defect of consolidation or pseudoarthrosis. The planar study
—delayed images in plantar projection of both feet (A) and external lateral projection of the left foot (B) and early image (C) and the SPECT/CT study— and the coronal slices
of both feet (D), and the corresponding selected CT and fusion SPECT/CT sagittal (E) and axial (F) slices of the left foot showing an increase in uptake in the proximal lthird of
the fifth metatarsal diaphysis with an increase in vascularization in the early image (arrow), indicating the persistence of intense osteogenic activity in the site of the fracture
with no signs of morphological consolidation and with only the presence of a small bone bridge in the external margin (arrow) in the CT image.

BS may help to evaluate this pathology, ruling out the possibility
of an occult fracture as the cause of pain. The scintigraphic image
is similar to that of any inflammatory arthropathy. Delayed bone
images show generalized increased uptake in the articulation and
the periarticular bone secondary to an increase in blood perfu-
sion, which produces inflammation of the synovial membrane on
the articular surface or in zones of reactive bone neoformation in
the adjacent bone. Early angioscintigraphic images show a variable
grade of increase of activity in the articulation affected depend-
ing on the time of evolution and the severity of the lesion, and the
intensity of activity observed in these images correlates with the
grade of inflammation of the joint affected.14
Type I complex regional pain syndrome
Reflex sympathetic dystrophy or type I complex regional pain
syndrome is the post-traumatic sequela of a focal or diffuse sports
lesion and is more frequent than previously considered. It may
especially be produced in contact sports and can be detected with
a high grade of sensitivity by BS. This painful syndrome has a little
understood physiopathological mechanism, and the level of pain is
not proportional to the triggering event or the expected response
to healing. It can be defined as exaggerated or abnromal response of
the sympathetic nervous system. It is characterized by the presen-
tation of vasomotor instability with trophic and vascular alterations
accompanied by pain, edema and functional limitation that affects
all of the affected extremity as a whole. All the tissues and struc-
tures from the superficial plane of the skin to the deepest plane
of the bone are involved. The vascular changes may be shown in
early BS images which present an increase in periarticular activity,
and the adjacent bone shows a local increase in bone remodeling
with some reabsorption, which explains the presence of radiologi-
cal and scintigraphic changes in this process as well as changes at a
synovial level.21 This syndrome has a wide spectrum of clinical pre-
sentations, and the clinical course can be divided into three stages:
stage I or the acute or inflammatory phase, stage II or dystrophy
and stage III or atrophy. This division, however, is not as clear in
practice since the three stages overlap over time. The characteris-
tic localizations are the upper and lower extremities, involving a
part of or all of the extremity. Although the diagnosis depends on
the clinical evaluation, 3-phase BS presents the changes earlier than
radiology and is useful for diagnosis of the disease. This approach
has a very good correlation with the clinical course to determine
the stage of the process, providing information on vasomotor sta-
tus by evaluating the grade of hyperemia in the early and dynamic
study, in the follow-up and in the determination of the prognosis.
In addition, 3-phase BS can rule out other diagnoses. The scinti-
graphic patterns depend on the duration of the process, the age of
the patient, the triggering damage and the localization of the lesion.
In the acute stage, within the first 20 weeks, the three phases of
the BS show an increase in activity with diffuse hyperemia in the
affected hand or foot and diffuse increased uptake in the articu-
lar and periarticular surfaces which may affect all the articulations
of the symptomatic extremity and especially the distal articula-
tions in the delayed images. This pattern is useful for making the
diagnosis and differentiates the pattern of atrophy by inactivity of
the extremity. At 5 months and up to 15 months, during the dys-
trophic stage, the first two phases of BS progressively normalize,
and the delayed images show persistence of a periarticular increase
of uptake. After 15 months, during the atrophic stage, there is a
reduction in perfusion, showing normal or reduced activity in the
first two phases and with normal radiotracer uptake in the delayed
images. In children, a reduction of activity in the early phases of BS,
due to a reduction of perfusion, and decreased uptake in the delayed
phase, are the most common manifestations and is a pattern that is
rarely found in adults. The diagnostic sensitivity of BS in this pro-
cess varies from 73 to 96% with a specificity of 86–100%, being an
excellent imaging modality for ruling out this syndrome and having
a high negative predictive value.8,14,20,22 It is less sensitive and spe-
cific for the diagnosis of this process in children. A SPECT/CT study
is useful when there is suspicion of additional or concomitant focal
bone or articular lesions of a somewhat dystrophic process.
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Table 1
Representation of the Roub diagram (1979).The diagram shows the continuous bone response to an increase
in the level of stress and its relationship with the appearance of the symptomatology of pain, changes in bone
scintigraphy and simple radiography according to the level of stress.
F: formation; R: reabsorption.
Stress or overload bone lesions. Stress fractures
Bone stress lesions are a type of fracture that is secondary to
repeated and gradual low magnitude bone overload over a vari-
able period of time. This overloading leads to cyclic overload to
the bone which may cause bone damage and will increase, making
bone remodeling and repair processes unable to cope with these
repeated mechanical forces and will finally surpass the capacity
of resistance of the skeletal system. They represent a spetrum of
lesions: the earliest are periostic reaction and the response of bone
to stress, and the most severe is a complete or transosseous stress
fracture. These lesions can occur in a normal musculoskeletal sys-
tem, that is or is not trained, and in which the muscle is exposed to
excessive and maintained demand which the system is unable to
support and thus fails, constituting the so-called fatigue fracture.
When the lesions occur in a deficient system with a reduction in
elastic resistance of the bone, despite a normal muscular demand,
the so-called insufficiency fractures are produced. This is the case of
fractures in patients with reduced bone mineral content as well as
in osteoporosis of any etiology and in other metabolic bone diseases
such as Paget’s disease, among others.8
The classical diagram of Roub et al.23 systemized (Table 1) the
physiopathological sequence and the scintigraphic and radiologi-
cal findings of stress lesions in relation to the magnitude of stress
applied and the corresponding response of the bone. The phys-
iopathologial bone changes are clinically manifested and are shown
early in BS and delayed in radiological studies.23,24 When stress is
applied to a bone reabsorption of the laminar bone is produced,
which physiologically induces a local osteogenic reaction that leads
to a denser bone in order to strengthen the zone affected (normal
remodeling). If the stress is repeated and persistent, accelerated
subperiostic reabsorption is produced which weakens the mechan-
ical bone resistance, and although reactive neoformed bone is
simultaneously deposited, there is a vulnerable period in which the
bone presents greater bone reabsorption than forming capacity and
microfractures are produced in the trabecular bone. If the lesional
stimulus persists, bone fatigure will lead to a true stress fracture,
with the last stage of the lesion being progression to structural
failure with complete fracture.25 Multiple factors can contribute
to the appearance of stress fractures, including hormonal factors,
metabolic, nutritional components as well as anatomical predis-
positions such as differences in the length of the extremities, flat
feet/cavus foot and an increase in the Q angle which can increase
the risk of fracture.5
Ten percent of all sports injuries correspond to stress frac-
tures, and from 4.7 to 15.6% of these lesions are found in runners.
Most athletes presenting stress fracture report progressive, local-
ized pain which initiates during or after exercise and persists or
increases if the exercise continues. Physical examination shows
local sensitivity of the bone affected and, on occasions, edema.3,5
The radiological study may be normal during the first 3–4 weeks
after the onset of pain and may even never be positive if the stress
ceases, being of scarce utility for the ddiagnosis of acute stress frac-
tures. To the contrary, BS plays a relevant role in the early diagnosis
of these lesions and is essential to avoid progression to a complete
stress fracture, being pathological at 6 to 72 h.8,26
In order to achieve correct evaluation of a bone stress lesion,
the localization of the lesion must be considered which will allow
classification of the lesion as a low or high risk fracture, the size of
the lesion (extension of the accumulation of microdamage) as well
as the competitive or athletic status of the individual. These are
important factors to establish therapeutic decisions and prognos-
tic assessment of the evolution of the fracture. The classification
of stress factors as lesions of high and low risk (Table 2) is made
according to the localization, direction of the load through the
fracture during walking, natural course of fracture healing and
associated anatomical preconditions. Low risk stress fractures are
characterized by having a natural history of favorable evolution,
being located in bone zones of compression and responding well
to modification of activity, with evolutive complications being less
probable. To the contrary, high risk fractures have a significantly
worse prognosis and more frequently present complications such
as delay in consolidation, evolution to non union, recurrence of frac-
ture in the same localization or progression to complete fracture. In
addition to the localization, the extension of the area of bone fatigue
or the grade of the stress lesion are necessary to complete the
description and evaluation of the lesión.3,27,28 In this sense, grad-
ing systems of bone stress lesions have been proposed which cover
all their spectrum, from the response to stress to complete fracture.
Matin24 and Zwas et al.29 described an already classical grading sys-
tem of bone stress lesions which are simplified into several stages
or grades (Table 3) based on the extension of the lesion in the thick-
ness of the bone in the scintigraphic image. This grading system can
be applied in long bones of the extremities. In this way, a spectrum
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Table 2
Classification of stress fractures in high and low risk fractures depending on their localization on the skeleton and within the same bone structure.
High risk
Femur (neck)
Tibia (anterior cortical diaphysis and internal internal malleolus)
Patella
Tarsal scaphoid bone
5.◦ metatarsal (proximal/base)
2.◦ metatarsal (base)
Sesamoids
Carpal scaphoid bone
Table 3
Stages of bone stress lesions from periostic reaction (stress reaction) to stress
fracture.
Stage % Involvement of Lesion
bone thickness
I 0-20 Minimum periostic reaction
II 21-40 Moderate periostic teaction
III 41-60 Initial stress fracture
IV 61-80 True stress fracture
V 81-100 Complete stress fracture (transosseus)
Source: Matin24 and Zwas et al.29
of these lesions is observed, going from the minimum periostic
reaction to a complete stress fracture. The initial periostic reeac-
tion is shown in the BS as a small linear image, which is discretely
active and confined to the cortical bone. If the process continues, the
active image enlargens and extends along the cortical bone, poste-
riorly progresses towards the bone marrow, acquiring a fusiforme
appearance, and finally occupying all the thickness of the bone, con-
stituting a transosseous fracture. The early phase BS images show
an increase in local vascularization shortly after the onset of pain
which later normalizes with evolution towards healing.
Later reports in the literature have described similar grading
systems of bone stress lesions based on the findings of other imag-
ing modalities such as CT and MR, and have demonstrated their
correlation with BS findings, especially those of the initial phases
of the lesion, correlating scintigraphic alterations and the increase
in the level of changes by periostic edema and of the bone marrow
visible in the MR.30
Key point
Correct evaluation of bone stress lesions requires consideration of
their localization and allows their classification as a high or low risk
fracture, their extension and the competitive status of the sportsperson.
Scintigraphic grading of these lesions with the contribution of SPECT/CT
to detect smaller lesions and more accurately determine their extension
facilitates diagnosis in the initial stages to thereby avoid progression
to a complete fracture.
Stress fractures have been described in numerous localizations
of the skeleton and in relaton to multiple sports. Their localization
is determined by the type of activity carried out together with other
previously mentioned predisposing factors so that the localization
of some fractures may be almost specific to each sport. Stress frac-
tures are more frequent in the lower extremities, corrresponding
to 80–90% of all stress factors, and they represent between 0.7 and
20% of all sports lesions (Fig. 4). The most common localizations are
the tibia (23.6%), the tarsal scaphoid bone (17.6%), the metatarsal
bones (16.2%), the fibula (15.5%), femur (6.6%), the pelvis (1.6%) and
the vertebral spine (0.6%), and likewise, they have been described
in sesamoid bones. Stress fractures in the thoracic region are rel-
atively less common, although they have been described in the
ribs of golfers, tennis players and rowers. Stress fractures in the
9
Low risk
Femur (diaphysis)
Pelvis (sacrum and pubic branches)
Tibia (diaphysis, proximal)
Fibula
Other tarsal bones
Metatarsal bones (diaphysis 1–4) and toe phalanges
Upper extremity (clavícle, scapula, humerus, olecranon, cubital, radius, metacarpal bones
Ribs
upper extremities correspond to less than 10% of all stress frac-
tures and more frequently occur in athletes participating in sports
with throwing activity, rowers or in other general activities. They
have been reported in the humeral diaphysis associated with hal-
terophilia and javelin throwing.2,3,5
Stress fractures of the tibia are the most frequently described
in sports medicine and are found in around 50% of all stress frac-
tures in athletes. The capacity of BS to visualize the spectrum of
bone stress lesions enables distinguishing these lesions from ente-
sopathic lesions such as shin splints, being of great clinical and
therapeutic importance. These fractures are frequently located at
the union of the middle third with the distal portion of the posterior
tibial cortical bone but may occur at any site along the diaphysis.
Tibial stress fractures are often multifocal and bilateral, and bilat-
eral tibial stress fractures may be observed in different stages in
the same athlete. In the scintigraphic study increased uptake of the
radiotracer is usually localized in the posteromedial cortical bone
with a typical rounded or fusiforme appearance with vertical ori-
entation of the lesion along the tibial diaphysis. However, in the
initial stages it is usually more linear and confined to the cortical-
periostic zone and corresponds to periostic reaction as the most
initial phase of a stress fracture.24,31,32 A SPECT/CT study helps to
more acurately determine the stage of the bone stress lesion and
can detect smaller sized lesions (Fig. 5). In children and adoles-
cent athletes, the fractures may have a horizontal disposition in
the proximal diaphysary third of the tibia, originating in the pos-
terior cortical bone and extending to the anterior cortical tibial
bone. These patients are often referred for suspicion of primitive
bone tumor due to their age and less frequent localization of stress
fractures in this zone. SPECT/CT study facilitates specific diagno-
sis in these cases. The distal third of the tibia is more frequently
affected in marathon runners. Stress fractures of the fibula cor-
respond to 20% of the pediatric population and 30% of the stress
fractures in adults and are preferentially localized in the distal
diaphysary third, proximal to the external malleolus and most fre-
quently occur in the practice of dancing, aerobics, gymnastics and
running12 (Fig. 6).
Stress fractures of the ankles and feet are localized in the
metatarsals in 55% of the cases, being the second and third bones
most frequently affected, corresponding to 90% of metatarsal frac-
tures (Fig. 7). Stress lesions in the scaphoids, astralagus, calcaneus,
cuboid bones and sesamoid bone may also be easily detected in
BS, and the addition of SPECT/CT allows accurate localization of the
lesión.26
Among the tarsal bones the calcaneus is the most commonly
affected, and similar to other fractures which occur in trabecu-
lar bone, the initial radiological study may be normal. The most
common localization of the fracture is in the posterior tuberos-
ity of the calcaneus and is usually represented as a linear band
of uptake of the radiotracer in the posterior half of the body of
the calcaneus, which in cases of incomplete or initial fracture may
only affect the upper half. Scintigraphic images are able to distin-
guish this from other lesions in the differential diagnosis such as
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Fig. 4. Stress fracture in the distal third of the diaphysis of the left tibia in a sportsperson with distal tibial pain of 3 weeks of evolution which initiated after intensification of
training prior to a marathon. The planar bone scintigraphy —early image (A) and delayed bone images in anterior projection (B) and internal lateral projectiony (C)— showing
a linear increase of uptake in the internal side of the distal diaphysary third and slight associated hyperemia (arrow) and very mild diffuse increase of activity extending
distally to the distal tibial epiphysis. The SPECT/CT study —selected fusion coronal SPECT/CT images (D), CT and coronal (E), sagittal (F) and axial fusion SPECT/CT images
(G)— localizing an increase in uptake affecting the anterointernal tibial cortical bone with slight extension to the adjacent endostic area, representing reparative osteogenic
activity in the site of cortical fracture with signs of periostic and endostic reaction in the CT image.

Fig. 5. Two cases of athletes with tibial stress fracfures are shown in different evolutive stages of the lesion. (A–C)Perisotic stress reaction as the earliest stage of the bone
stress lesion in the middle third of the diaphysis of the right tibia in a marathon runner. The scintigraphic images — planar study (A); delayed images in anterior and left
internal lateral projection and SPECT/CT study: selected coronal (B) and axial slices (C)— showing a small linear osteogenic reaction (arrow) limited to the posterointernal
periostic-cortical area of the middle third of the diaphysis of the right tibia (arrow head). Case of an adolescent athlete with a stress fracture in the union of the proximal
third with the middle third of the diaphysis of the left tibia. (D) Delayed scintigraphic images in anterior projection of both tibias and left internal lateral projection and
SPECT/CT images — fusion sagittal SPECT/CT (E) and axial CT slice and fusion SPECT/CT (F)—. Increased focal uptake of the radiotracer affecting the posteromedial cortical
bone of the proximal-middle diaphysis of the left tibia and with endostic extension and slightly to the bone marrow and slight thickening of the cortical bone in the CT image,
representing reparative osteogenic activity in the fracture (stage III-IV of the scintigraphic classfication of the bone stress lesions).

plantar fascitis, Achilles tendon enthesopathy and retrocalcaneal Pain of the plantar side of the head of the first or second
bursitis.24,31 SPECT/CT provides more accurate evaluation of the metatarsal bone is common in sportspersons and is often diffi-
grade of stability of the fracture and the need for surgery.12 cult to localize and assess. Sesmoid bones located on the plantar
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Fig. 6. Stress fracture in the distal third of the fibula in a dancer presenting pain in the external side of the ride ankle of 20 days of evolution with a negative radiological
study. The planar study images (A–C) show intense hyperemia (arrow) and an increase in uptake in the distal third of the right fibula. The SPECT/CT images (D–F) confirm an
intense increase of reparative osteogenic activity in the site of the fracture with traces of fracture in the anterior and posterior cortical bones in the CT image (arrows).

Fig. 7. Acute stress fracture in the second metatarsal of the right foot in a runner reporting pain of 15 days of evolution. The planar study images (A–C) and the images of the
SPECT/CT study —selected corresponding coronal (D), sagittal (E), and axial slices (F) of CT and fusion SPECT/CT and 3D reconstruction (G)— showing a characteristic aspect
of metatarsal stress fracture, presenting reparative osteogenic activity in the site of the fracture of the distal third of the diaphysis of the second right metatarsal bone, with
an increase in vascularization in the early image (arrow) and greater intensity in the plantar cortical bone and lateral diaphysis.

side of the head of the first metatarsal bone are two bones sur-
rounded by the short flexor muscle tendon of the first toe of the
foot and are found inside the capsule of the first metatarsopha-
langeal joint. The presence of bipartite or multipartite sesamoid
bones in 5–30 % of individuals as a anatomical variant of normality
make radiological diagnosis of the fracture of these bones diffi-
cult. Increased radiotracer uptake in the sesmoid bone indicates
the presence of a recent fracture and allows differentiation from
the bipartite sesamoid bone. SPECT/CT with morphlogical charac-
terization of the sesamoid bone in the CT image demonstrates the
diagnosis of lesion in this bone.12,14 Activities involving the great-
est incidence of stress fracture in sesamoid bones include ballet,
dance, football, running and jumping.
Stress fractures of the neck of the femur correspond to approx-
imately 4.5% of all stress fractures. Two main types of these
fractures have been described: transversal or tension fractures and
compression fractures. Transversal fractures are produced in the
superoexternal zone of the femoral neck and are potentially unsta-
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ble. In addition, these fractures most often occur in older patients
and are predisposed to displacement since a lack of continuity is
produced in the zone of tension of the femoral neck making these
patients candidates for surgical fixation treatment. SPECT/CT shows
a line of uptake that corresponds to a fine sclerotic line in the CT
image on the superoexternal side of the femoral neck which pos-
teriorly transversally extends to all of the neck of the femur.
Compression fractures are localized in the medial zone of the
femoral neck where the forces of compression predominate. They
are therefore stable fractures, with conservative treatment being
the treatment of choice if there is no displacement since these
fractures heal well with rest. Compression fractures are the most
common type of fracture and usually occur in young sportspersons.
They are frequently observed in the months following intensifica-
tion of physical and sports activity and in practically any type of
sport, although they are more frequent in long distance runners.
When there is no displacement, they may be difficult to detect since
the initial symptomatology is usually insidious, and there are no
alterations in simple radiography. Nonetheless, it is important to
suspect this type of fracture since they have a limited therapeutic
period to avoid evolution to a more extensive fracture. In BS they
are shown as a small increased uptake in the convave portion of
the femoral neck, which in the SPECT/CT study may coincide with
a minimal sclerotic line in the inferointernal zone of the femoral
neck in the CT which may become larger with evolution. The utility
of SPECT/CT in the diagnosis of these fractures is evident, allowing
differentiation from other processes with which differential diag-
nosis is established in sports medicine, such as tendinitis of the
hip, trochanter bursitis, and in general, with other coxopathies and
avascular necrosis of the head of the femur.12,14
Spondylolysis
Lumbar pain is one of the most frequent symptoms associated
with any type of athletic activity. In most cases the etiology is mus-
cular or potentially radicular and is confirmed by CT or MR. When
the origin might be osseous, BS, always together with SPECT or
SPECT/CT, are the studies of choice. It has been described that bone
SPECT of the lumbosacral spine increases the sensitivity for the
detection of lesions by 20–50% compared to planar BS, especially in
the posterior elements of the vertebrae.21 The etiology of lumbar
pain in young athletes differs from that of adults. The bone cause
is more frequent than discal disease, and spondylolysis is the most
common bone cause. Other etiologies that should be taken into
account include other localizations of bone stress lesions within the
vertebrae and in the pedicles, spinal apophysis and associated with
defects in the vertebral laminae, mechanical rachialgia, vertebral
apophysitis or Scheuermann disease, transitional lumbosacral ver-
tebra syndrome (Bertolotti syndrome), interspinal lumbar bursitis,
degenerative alterations in vertebral processes, fractures in sacral
facet joints, and in the case of adolescent athletes, the possibility of
fracture due to avulsion of the centers of secondary ossification.33
Some studies have demonstrated that lumbar pain with or without
irradiation to the lower extremities may be secondary to lumbar
vertebral disease and also disease in sacroiliac joints, the sacrum
or in the hips. In this sense, long distance female runners have a
slightly greater risk of stress fractures in the sacrum, which may be
clinically manifested as lumbar pain and in the region of the but-
tocks, simulating radicular pain.34,35 The diagnosis of extraosseous
lesions (soft tissue, musculotendinour or ligamentous lesions) may
be obtained with a greater degree of certainty in the case of a normal
scintigraphic study.
Spondylolysis is a defect of the pars interarticularis or isthmus of
the vertebra, which affects 5–7% of the population. It is more fre-
quent in males and corresponds to approximately 15% of pediatric
stress fractures.12 In the sports setting, spondylolysis is considered
a a fatigue fracture secondary to abnormal, chronic or repeated
stress on the vertebral spine in a subject with predisposing factors,
and it is 3 to 4-fold more frequent than in the genral population,
varying from 15 to 25% depending on the statistics.8 Isthmic ver-
tebral lesions are observed in sports involving flexoextension such
as gymnastics or butterfly style swimming. They are occasionally
associated with rotations such as in tennis, high jumping or javelin
throwing and in compression or simultaneous load such as in hal-
terophilia, trampoline jumping or taekwondo. A radiologic study
can identify a unilateral or bilateral defect of the isthmus of the
vertebrae, but this radiological finding does not justify the pres-
ence of lumbalgia since this lesion is often asymptomatic and, on
occasions, is incidentally discovered in a radiography obtained for
other purposes. These fractures are usually bilateral, affecting L5 in
85–95 % of the cases and L4 in 10%. Involvement of more proximal
lumbar vertebrae is rare and is usually unilateral. Unilateral isthmic
lesions are observed in 14–30 % of the cases. In 50% of the cases with
a bilateral defect, lysis evolves towards spondylolisthesis, while if
the defect is unilateral, the displacement is scarce or nul.14,31
Scintigraphic study can differentiate acute spondylolysis from
fractures or a old or chronic non binding isthmic defect, and there
is a good correlation between scintigraphic uptake and the painful
lesion of the pars interarticularis. For evaluation of young athletes,
BS, always with a tomographic technique (SPECT or SPECT/CT),
plays a key role in the detection of the spectrum of stress bone
lesions of the pars interarticularis. This spectrum of bone lesions
includes bone stress response without morphological spondylol-
ysis in which the scintigraphic study shows an increase is isthmic
uptake of the radiotracer with no associated radiological alterations
or with bone sclerosis without a fracture line in the CT image to
confirm the diagnosis of occult stress fracture (spondylolysis in a
preradiological phase or “in formation”); morphological spondy-
lolysis with an abnormal radiological study with a fracture line in
the pars interarticularis, in which the scintigraphic study shows the
localization and the intensity of the metabolic bone activity indi-
cating the presence of a metabolically active lesion which confirms
that the isthmic defect is the cause of recent lumbar pain (Fig. 8),
and an old cured lesion with signs of non binding of the defect with
no increase in osteogenic activity in the scintigraphic study, which
is associated with the fracture line with sclerotic margins in the
CT image. Physiological information of the lesion allows adequate
treatment to be implemented. In this sense, the use of lumbar SPECT
or SPECT/CT as a follow-up technique should be noted in athletes
with symptomatic spondylolysis to decide the most adequate ther-
apeutic approach and the time at which the athlete can return to
competition.
Unilateral spondylolysis may be associated with a contralateral
stress response in the pars or in the pedicle which is demon-
strated by uptake of the radiotracer in SPECT and sclerosis in the
CT image.35
Key point
For the diagnosis and evaluation of athletes with symptomatic
spondylolylsis, BS, always with SPECT or SPECT/CT, has a key role,
and can detect the spectrum of bone stress lesions of the pars
interarticularis, which includes bone stress response without morpho-
logical spondylolysis (spondylolysis «in formation»); morphological
spondylolysis with metabolic bone activity (metabolically active
spondylolysis),and lesions without an increase of osteogenic activity
(metabolically inactive spondylolysis).
The utility of bone SPECT or SPECT/CT is also of note in the
evaluation of the vertebral facet syndrome and of other possible
previously mentioned bone causes of lumbar pain. SPECT/CT is able
to determine the exact localization of the lesion without increasing
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Fig. 8. Tennis player of 18 years of age who presented lumbar pain of 4 months of evolution with no history of previous trauma and with radiological bilateral spondylolysis
in L4. (A) Planar scintigraphy. Selective posterior projection of the lumbosacral spine. Focal uptake of the radiotracer in the external margins of L4. SPECT/CT study of the
lumbosacral spine —corresponding selected coronal (B), right (Ca) and left sagittal (Cb) and axial slices of L4 (D) of the CT and fusion SPECT/CT and detail of the corresponding
axial CT and fusion slices of L4 (E)—. Increased focal uptake of the radiotracer in both isthmic regions of L4 that show the localization of the increase of metabolic bone activity
that coincide with the bone defect with a fracture line in the pars interarticularis of L4 (arrows) in the CT image, which indicates a metabolically active spondylolysis in L4.

the metabolic bone activity which, together with its morphological
characterization, can achieve a specific diagnosis.20,34–36
Enthesopathies
Enthesopathies are skeletal lesions secondary to mechanical
overload occurring in the enthesis, that is, in bone zones in which
fixation tissues are inserted into the muscle (tendons and con-
nective fibers), ligaments and articular capsules. Enthesopathies of
sports origin may be defined as mechanical inflammation of the
musculotendinous unit in the zone of bone insertion as a defensive
response to microtraumatisms due to repeated muscular overex-
ertion or overload. Abnormal repeated or forced traction applied to
this union in the periostic interphase affecting the Sharpey fibers
triggers a periostic and cortical reaction of accelerated bone remod-
eling which leads to an increase in focal osteogenic activity and can
be demonstrated by BS. The natural evolution of an enthesopathic
lesion consists in the appearance of granulation tissue in the area
of insertion, which is progressively replaced by fibrocartilage and
undergoes an ossification process in advanced phases. This type of
lesion, and especiallyin the acute phase, is associated with a normal
radiological study. The BS study constitutes a highly sensitive and
accurate diagnostic test that demonstrates the metabolic perios-
tic or bone reaction triggered at the point of fasciotendinous or
ligamentous union and allows evaluation of the intensity of the
lesion and its evolution after treatment, ruling out other diagnostic
entities such as stress fracture, purely muscular lesions or bursi-
tis.
Enthesopathies of the lower extremities
The “medial tibial stress syndrome” or “shin splints” is clinically
characterized by pain and heaviness in the lower half of the leg of
athletes and has a determined biomechanical cause. This syndrome
involves a periostic reaction along the origin of the soleus muscle
and its fascia, the long flexor muscle of the toes, or to a lesser extent,
of the posterior tibial muscle produced by traction of these muscles
on the periostic zone to which they are fixed in the posterior side
of the tibia, with rupture of the Sharpey fibers between the muscle
and the bone. The radiological study of this lesion is normal while
having a characteristic scintigraphic appearance. The early phase is
normal, and the delayed phase is characterized by an active linear
image of variable intensity localized along the posteromedial bor-
der of the middle or distal third of the tibia secondary to a periostic
reaction in the area of muscle insertion, often being bilateral. When
the muscle involved is the anterior tibial muscle, increased uptake
is localized in the proximal two thirds of the anterolateral border
of the tibia. Differential diagnosis should be established with stress
fractures (Table 4) and with the compartmental syndrome. In the
latter, which is primarily of muscular origin, the BS is, in principal,
normal.8 Likewise, in the same patient stress fractures and shin
splints may coexist (Fig. 9).
Key point
Metabolic periostic or bone reaction in the enthesis demonstrated
in the scintigraphic study allows evaluation of the intensity of the
enthesopathic lesion and its evolution after treatment as well as rul-
ing out other diagnoses such as stress fractures and lesions exclusively
of the soft tissues, with SPECT/CT being of note in the distinction of
the latter. The capacity of scintigraphic studies to distinguish between
a tibial stress fracture and an enthesopathic lesion (shin splints) is
fundamental for adequate therapeutic decisions making.
«Thigh splints» correspond to a lesion that is equivalent to shin
splints, but they are localized in the medial cortical bone of the
proximal and middle third of the diaphysis of the femur in relation
to the insertion of the adductor muscles. This pathology is much less
frequent and was first described in short female military recruits.32
Enthesopathies that affect the extensor apparatus of the knee
are scintigraphically observed in the early and delayed phases as
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Fig. 9. A) Bilateral tibial shin splints in an 18-year-old high jumper who reported disturbances in both shins of 2 months of evolution of post-training onset and with a normal
radiological study. The planar scintigraphy study—delayed images of both tibias in anterior and lateral and left projection — showing characteristic scintigraphic findings
in this type of enthosopathic lesion with a linear increase of tradiotracer uptake in the posteromedial border of the middle third of the diaphysis of both tibias, being more
extensive in the left tibias (arrows), indicating periostic reaction in the zone of muscle insertion. (B–E) Study showing the coexistence of bilateral shin splints in the same
athlete affecting the anterior border of the proximal two thirds of both tibias and of a stress fracture in the middle third of the diaphysis of the right tibia. B) Delayed planar
images —anterior projection of both tibias, lateral interanal of the right tibia and selective image magnified with a pinhole collimator in the middle third of the right tibia—
and the images of the SPECT/CT study —selected axial fusion SPECT/CT slices of both tibias (C) and coronal (D) and sagittal slices (E) of the right tibia— showing the localization
of the insertional anterior periostic reaction in both tibias corresponding to the anterior enthesopathic tibial lesion (arrow heads) and the focus of reparative osteogenic
activity surrounding the posteromedial cortical bone of the middle third of the diaphysis of the right tibia (arrow) indicating a stress fracture limited to the cortical bone
(evolutive scintigraphic stage II-III).

Fig. 10. This figure shows two cases of different patients presenting characteristic images of the enthesopathies that affect the extensor apparatus of the knee. Case 1. Left
infrapatellar enthesopathy in a volleyball player with knee pain of 5 months of evolution. (A) Planar study: early image and delayed images of both knees in anterior and
internal left lateral projection. SPECT/CT study: selected left sagittal (B) and axial slices (C) of CT and fusion SPECT/CT and selected and more medial coronal and left sagittal
slices of CT and fusion SPECT/CT (D). Increased focal uptake of the radiotracer in the proximal insertion of the patellar tendon in the lower pole of the left patella coinciding
with small irregularities in the patellar bone margin in the CT image. (D) In the case of this patient, an increase in focal uptake in the middle half of the articular region of the
middle third of the left patella is of note (arrow) coinciding with small subchondral cysts and sclerosis in the CT image, corresponding to a patellar osteochondral lesion with
an increase in metabolic bone activity. Case 2 (E). This corresponds to enthesitis in an anterior tuberosity of the right tibia in a cyclist reporting selective pain in this zone.
The images of the SPEC/CT study show focal periostic reaction in the distal insertion of the patellar tendon, in the anterior right tibial tuberosity, representing a metabolically
active enthesopathic lesion (arrows).
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Table 4
Scintigraphic patterns and findings in simple radiography in shin spints and in stress fractures.

Stress fracture Shin splints

3-phase bone scintigraphy Any phase is + Only delayed or bone phase, is +

Shape Rounded/fusiforme Linear/vertical
Localization Any localization of the tibia Middle-distal third posterior diaphysis or proximal anterior two thirds of the tíbia (m. anterior)
Simple radiography Later + (minimum 3 weeks) Always normal

Fig. 11. (A) Two-phase planar bone scintigraphy — early image of both feet and selective delayed image of the right foot in internal lateral projection — and SPECT/CT images
—selected sagittal and coronal slices of CT and fusion SPECT/CT (B) of the right foot— in a case of right Achilles enthesitis in a tennis player presenting talus pain of 3 months
of evolution. Focal increase of radiotracer uptake in the middle third of the posterior bone border of the right calcaneus with focal hyperemia (arrow) in the early image.
The sagittal and coronal SPECT/CT images localize the uptake in the calcaneal insertion of the right Achilles tendon, indicating a local inflammatory process with reactive
periostitis in the insertional zone. (C) Planar scintigraphy study —early image and delayed image of both feet in internal lateral projection—and SPECT/CT study —selected
sagittal and axial slice of CT and fusion SPECT/CT (D)— showing the characteristic findings of plantar fascitis with increased focal uptake in the left calcaneal tuberosity in
the zone of insertion of the plantar fascia, which is accompanied by an increase of vascularization in the early image (arrow). The CT image localizes greater intensity of the
insertional periostic reaction in the internal half of the calcaneal tuberosity and shows the presence of a small associated calcaneal spur.

foci of increased radiotracer uptake in the zones of fixation of the
quadriceps muscle at the base of the patella (quadricipital enthe-
sopathy) or of the patellar tendon at its proximal insertion in the
patellar vertex or at its distal insertion in the anterior tibial tuberos-
ity. In the last case, in adolescents this should be differentiated
from Osgood-Schlatter disease. In lesions of long evolution the early
phase is usually normal. The most common lesion is that which
affects the insertion of the patellar tendon into the inferior pole of
the patella and is frequent among athletes involved in jumping or
throwing sports, volleyball, basketball and halterophilia and con-
stitute the so-called jumper’s knee or infrapatellar enthesopathy
(Fig. 10).
Among the enthesopathies of the foot, Achilles tendon enthe-
sopathy is of note. In the acute phase of the lesion the scintigraphic
study shows an increase in uptake in the zone of calcaneal inser-
tion of the Achilles tendon along the middle and upper third of
the posterior surface of the calcaneus. Diagnosis in this phase is of
great importance before later aggressions to the damaged tendon
can cause its rupture. This lesion is common among sportspersons
and normally develops after prolonged periods of intensive training
with defectuous or excessive dorsiflexion mechanics which pro-
duce repetitive microtrauma. It may be associated with Haglund
deformity of the calcaneus with thickening in the bone prominence
of the posterosuperior zone of the calcaneus. Haglund disease
includes the triad of Haglund deformity, an insertional tendinopa-
thy which is frequently of the calcifying type and retrocalcaneal
bursitis and retro achilles bursitis.37
Plantar fascitis is one of the most frequent lesions due to over-
load as a cause of thalalgia in athletes, making up around 8% of
these lesions. In most cases it is the result of a biomechanical
alteration which carries abnormalities in pronation. Predisposing
factors include failure in the biomechanics of the foot such as the
presence of cavus foot, varus or valgus feet or asymmetry of the
lower extremities, overtraining or the use of inadequate footwear.
It is a traumatic inflammation of the fascia and of the perifas-
cial soft tissue secondary to stretching or tearing of the plantar
fascia and caused by overextension and repeated microtrauma by
traction with mechanical stress which produces localized reac-
tive periostitis in the calcaneal tuberosity. Scintigraphically it is
characterized by a focal increase of the radiotracer uptake at the
inferior border of the calcaneal tuberosity at the zone of origin of
the plantar fascia and, on occasions, in the insertion of the plantar
fascia in the proximal phalangeal bases. Similar to Achilles enthe-
sopathy, it does not usually have radiologial translation, except in
chronified processes and with calcifications and in cases in which
a calcaneal spur is observed, which only appears in 50% of symp-
tomatic patients and in 10–16% of asymptomatic patients.14 BS is
useful to confirm the diagnosis as well as for guiding therapeu-
tic injection of corticosteroids and to evaluate response to this
treatment, demonstrating a reduction in osteogenic activity after
the corticosteroid injections.26 The scintigraphic findings in plan-
tar fascitis can be clearly differentiated from those observed in
other causes of thalalgia in athletes and can be diagnosed scinti-
graphically. These findings include tendinopathies and Achilles
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Fig. 12. Right lateral epicondylitis in a tennis player reporting pain in the external side of the right elbow with irradiation to the forearm of 5 months of evolution. (A) Planar
images of both elbows: early phase and delayed bone phase (A). SPECT/CT study of the right elbow: selected coronal (B), sagittal (C) and axial slices (D) of CT and fusion
SPECT/CT and selected axial fusion slice (E). Increase of uptake in the lateral epicondyle region of the right humerus (arrows), with mild hyperemia in the early image, which
SPECT/CT accurately localized in the lateral epicondyle periosteum, confirming an enthesopatic lesion with an increase of metabolic bone activity.

enthesopathies and bursitis, calcaneal apophysitis, calcaneal stress Pelvis

fractures and retrocalcaneal bursitis. SPECT/CT can accurately show
the point of insertion of the Achilles tendon and of the plantar fas-
cia in the calcaneus and demonstrate its relationship with the focus
of pathological uptake of osteogenic activity, allowing the specific
diagnosis of these diseases. As additional information, SPECT/CT
allows the visualization of opacifications of the Kager fat pad in the
CT image in Achilles tendinitis12 (Fig. 11).
Enthesopathies of the upper extremities
Enthesopathic lesions of the elbow include tennis elbow, which
is an of the epicondyle muscles, and medial epicondylitis, which
is a lesion of overload in the insertions of the flexor and pronator
muscle group that insert into the epitroclea. It is less frequent than
lateral epicondylitis and only represents 10% of elbow tendinitis.
An image of increased focal uptake at the point of osetotendinous
insertion is diagnostic of these lesions and distinguishes them from
another type of lesion which may occur in this zone such as osteo-
chondritis dissecans, stress fracture of the head of the radius or
olecranon lesions such as fracture or bursitis (Fig. 12). SPECT/CT
especially improves the images of complex lesions of the elbow and
can identify each of these lesions as in cases of osteocondral lesions
associated with insertional lesions or in collateral ligaments.12
Another enthesopathic lesion of the upper extremity is humeral
periostitis or Ringman lesion with a physiopathology and scinti-
graphic findings that are equivalent to those of shin and thigh
splints. This type of lesion is usually bilateral and frequent in
sportspersons who practice halterophilia and ring gymnastics. BS
shows an increased linear uptake of the radiotracer in the proximal-
medial third of the humeral diaphysis in relation to the area of
insertion of the pectoralis major muscle. In the forearn enthesopa-
thy can be detected in the insertion of the bicipital tendon into the
bicipial tuberosity of the radius and enthesitis in the insertion of
the brachioradialis tendon into the radial styloid process.8
Osteopathy of the pubis or stress of the pubic symphysis rep-
resents the effect of overload in the origin of the long adductor
muscles, the gracilis muscle or internal rectal muscle and of the
rectus abdominis which produces tension or abnormal shear in the
symphysis of the pubis.This frequent lesion is developed in football
players, basketball players, ballet dancers and runners. Radiologi-
cal studies may be negative, and the alterations appear late and
in chronic lesions and are mainly indicative of cortical bone reac-
tion to continuous muscle tension caused by functional overload.
BS is able to detect alterations shortly after the onset of the clini-
cal manifestations, with a bilateral increase of radiotracer uptake
in the branches of the pubis and symphysis with narrowing of the
relatively photopenic fibrocartilaginous symphysis.32 Evidence of a
stress response may simply involve limited uptake at the insertion
of these muscles, but there may occasionally be a frank stress frac-
ture with increased uptake which extends to all the width of the
pubic branch. SPECT/CT images can easily differentiate the phys-
iological activity from the urinary bladder of the bone uptake as
well as evaluate chronicity of the lesion with the presence of cor-
tical sclerosis and early formation of cysts in the articular area of
the symphysis in the CT image.31 Differential diagnosis is made
with tendinitis of the adductors, stress fracture of the pubic or
ischiopubic branches and of the proximal third of the femur.
Avulsion bone lesions
Fractures by avulsion or bone tearing are caused by brusque
tension of a muscle or tendon on the bone and are more frequent
in adolescents and young individuals with immature skeleton in
whom the apophysary insertions are less strong than the tendon-
bone interphases. Within the context of sports, these lesions may
even occur in mature skeletons due to the strong concentrations
of force associated with overstretching of the musculotendinous
complex. Tearing is usually produced by indirect trauma which
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Fig. 13. Avulsion bone lesion of right accessory tarsal scaphoic bone producing accessory tarsal scaphoid syndrome in a sportsperson presenting an episode of forced inversion
of the right foot two and a half months previously with persistence of pain in the middle border of the mediotarsal region, selective in the right scaphoids area. Two-phase
planar study —delayed images in anterior projection (A) and internal lateral projection of the feet (B) and early image (C)— and SPECT/CT study —selected axial (D), sagittal
slices of the right foot (E) and coronal slices (F) of CT and fusion SPECT/CT—. Focal accumulation of the radiotracer in the proximal and medial segment of the right tarsal
scaphoid bone with intense focal hyperemia in the early image (arrow). The SPECT/CT study shows the presence of the accessory scaphoid bone in the CT image, and the
fusion images localize the pathological uptake of osteogenic activity secondary to the disruption of the union of the accessory bone with the principal scaphoid bone.

constitutes a true autotraumatism, and asynchronism between the
agonist and antagonist muscles during force, with violent muscle
contraction in the zone of insertion into the bone being responsi-
ble for this tearing.21 The apophyses of the pelvis and the hip are
especially susceptible since they appear and fuse later than those
of any other localization. In most cases the apophyses involved
are the anterosuperior iliac spine, the anteroinferior iliac spine
and the ischiatic tuberosity. The sports mainly involved are track,
figure skating, football and swimming. The scintigraphic findings
depend on the displacement of the bone fragment and the time
since the lesion occurred, showing a focal and often intense increase
of uptake of the radiotracer in the acute or recent lesion that repre-
sent the phenomena of bone repair. The addition of a SPECT/CT
study can determine the exact anatomical localization and can
morphologically evaluate the torn bone fragment and the grade
of displacement which is of prognostic importance.12
Another type of bone lesion by avulsion is that of the tarsal
scaphoid bone secondary or accessory to the scaphoids which con-
stitutes the scaphoid accessory syndrome. This small bone is an
anatomical variant of normality which is usually asymptomatic
and may have a fibrous or cartilaginous union with the main
scaphoid bone. It is located behind the posteromedial tuberosity
of the scaphoid bone and is present in 4–21% of the population,
being bilateral in 50–90% of the cases. On occasions, there may be
tearing of the tendon of the posterior tibial muscle which is par-
tially inserted in the accessory bone associated with the avulsion
bone lesion. The mechanism of the lesion may be traumatic and
secondary to forced inversion movements of the foot which is a
frequent mechanism in ankle or foot sprains due to overload. BS
shows a characteristic focal accumulation of the radiotracer in both
the early and the bone phase in the symptomatic medial border of
the tarsal scaphoid bone. The diagnosis is obvious in the SPECT/CT
study, with confirmation of the presence of the accessory ossicle
and its relationship with the increase of osteogenic activity21,37
(Fig. 13).
Another possible avulsion bone lesion is that related to the pres-
ence of bipartite patella. In the sports setting, this bone variant,
which is most cases is asymptomatic, may be painful after trauma-
tism to the anterior side of the knee or due to microtraumatisms
produced during sports activity which may produce a disruption
of the synchondrosis between the patellar fragment (superoexter-
nal in most cases) and the principal patella. The scintigraphic study
shows an increase of focal uptake in the patellar bone fragment,
and SPECT/CT can make the specific diagnosis by demonstrating
the presence of this bone variant and localizing the pathologic
osteogenic reaction secondary to its disruption of the patella.
Key point
The addition of a SPECT/CT study to BS makes it possible to obtain
a specific diagnosis of the pathology associated with accessory bone
by demonstrating the exact localization of the focus of increased
osteogenic activity in relation to the presence of the bone variant,
confirming its clinical significance as the cause of pain as occurs in
the accessory bone syndrome of the tarsal scaphoid bone. The same
approach is applicable to other symptomatic anatomical bone variants.
Other lesions related to sports injuries
Articular impingement syndromes
Femoroacetabular impingement
To explain the origin of hip arthrosis in young patients, alter-
ations in the shape and structure of the head of the femur initiating
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Fig. 14. Right talar compression syndrome in a dancer presenting persistent right supracalcaneal pain of 6 months of evolution. Planar bone scintigraphy —early image of
both feet (A) and delayed image in internal lateral projection of the right foot (B)— showing an increase of focal uptake in the posterior border of the right astralagus with an
increase of vascularization in the early image (arrows). The SPECT/CT study (C–E) shows the localization of the increase of osteogenic activity associated with the presence
of right os trigonum with sclerosis in the bone margin in the CT images, confirming a stress fracture of this ossicle, and allowing the diagnosis of the os trigonum syndrome.

articular degeneration were initially proposed. More recently, the
presence of structural alterations at the level of the femoral head-
neck transition or in the anterosuperior acetabular border has been
related to femoroacetabular trapping or impingement (FAI) as a
common cause of intraarticular pathology of the hip and secondary
osteoarthritis in young athletes. There are two basic mechanisms
for producing FAI: the “cam” type and the “pincer” type. In the cam
type the roundness of the femoral head is altered by the presence
of a bone prominence at the head-neck transition which in flex-
ion and internal rotation elevates the acetabular labrum and has
a harmful effect of direct compression within the anterosuperior
cartilage of the acetabulum, producing delamination. It is more
frequent in males and is directly correlated with early coxarthro-
sis in young adults. The pincer type is more frequent in middle
aged women who practice sports. The roundness of the femoral
head is normal, but the femoral neck rubs with the labrum by the
presence of a prominent anterolateral acetabular wall and over
time a kickback effect is produced in the posteroinferior margin
of the acetabulum. The mechanisms described are not normally
presented alone and in up to 70% of the cases a combination of
the two may be observed, with a slight predominance of one of
the two mechanisms. Femoral and acetabular signs suggestive of
FAI have been reported in 70% of radiographies of individuals less
than 55 years of age in whom total hip replacement had been
performed.38
Early diagnosis of FAI is of great importance to avoid severe
secondary articular damage. The clinical history and physical
examination reveal findings of articular damage in athletes, and
radiographies can demonstrate the presence of underlying FAI.
Scintigraphic study with SPECT/CT shows moprhological alter-
ations which produce FAI in the CT image and reflect the osteogenic
reactive activity and bone remodeling in the points of FAI, allow-
ing early diagnosis before the appearance of severe degenerative
articular alterations.39
Syndromes of articular impingement of the ankle
Posterior impingement syndrome of the ankle also known as
talar compression syndrome or of the tail of the astralagus or the
os trigonum syndrome is pathology characterized by pain on the
posterior side of the ankle triggered by forced plantar flexor move-
ments which produce repeated chronic microtraumat as occurs in
ballet, dance or sports such as football and track. Predisposing fac-
tors of note are the presence of os trigonum. This accessory ossicle is
presnt in approximately 3-13% of the population and the impact of
this osscicle between the calcaneus and the posteror border of the
tibia can lead to a stress fracture which is shown in BS as a focus of
increased uptake of the radiotracer in both the early and the delayed
phase of the study.14,40 As a consequence of the same mechanisms
of lesion, other causes of posterior impingement syndrome can be
included, such as the presence of a prominent or thickened pos-
teror lateral tubercle of the astralagus (Stieda tubercle), enlargened
posterior process of the calcaneus, free bodies or avulsion of the
posterior tibioastragalin ligament or any abnormal ossification or
calcification in the posterior side of the ankle. SPECT/CT provides
a specific diagnosis in this disease, showing the damaged anatom-
ical structure in the morphologial image (CT) with an increase in
osteogenic activity involved in the posterior impingement of the
ankle, differentiating whether this is secondary to a lesion in the os
trigonum or to other structures on the posterior side of ankle12,26
(Fig. 14).
In the syndrome of anterior ankle impingement, repeated dor-
siflexion of the ankle is the underlying mechanism of the lesion.
Anterior traction of the articular capsule of the ankle and fre-
quent contact of the astralagus with the tibia induce the growth
of hypertrophic spurs in the dorsal region of the astralagus, the
tibioastragalin articulation and the astragaloscaphoid articulation.
In the scintigraphic study, these areas of neooesthegenesis are visu-
alized as foci of increased uptake, with SPECT/CT indicating the
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Fig. 15. Osteochondral lesion in the right astralagus of a basketball player presenting the persistence of pain in the ankle after a fall with torsion 6 months previously. (A)
Planar scintigraphy study —early image (A) and delayed bone image of ankles and feet (B)—. Small increase of uptake in the superointernal margin of the right astralagus
with slight associated hyperemia (arrow). The SPECT/CT images (C–E) localize the increase of uptake in the subarticular region of the internal and posterior half of the dome
of the right astralagus, coinciding with cystic subchondral changes and sclerosis in the CT image.

exact location of the site of bone growth and its morphological
characterization.
Symptomatic tarsal coalition
Tarsal coalitions consist in the anomalous fusion between two or
more tarsal bones resulting in segmentation and abnormal differ-
entiation of the primitive mesenchymal tissue which leads to the
lack of formation of articulations. The prevalence of these coali-
tions is of 1–2 % and they may be single or multiple, being bilateral
in 50–60 % of the cases. According to the morphology and the char-
acteristics of the union between the tarsal bone, they are classified
in bone (synostosis) and non bone lesions: cartilaginous (synchon-
drosis) or fibrous (syndesmosis). Ninety percent of the coalitions
involve the calcaneoscaphoid and calcaneoastragalin articulations,
and the most frequent localization is the calcaneoscaphoid (50% of
the cases). Other articulations that may be affected are the astra-
galoscaphoid, calcaneocuboid and the cuboscaphoid. The clinical
presentation is variable: it begins in the second decade of life and
includes chronic pain in the lateral and anterolateral zone of the
ankle, flat and rigid feet, repeated sprains and a general limitation
of foot mobility.
The diagnosis is made by CT, but this study cannot differenti-
ate symptomatic from asymptomatic coalitions. SPECT/CT provides
a diagnostic window in this complex anatomical region, allowing
early detection of uptake in symptomatic coalitions as well as of
secondary osteoarthritis and occult coalitions, clearly demonstrat-
ing pathological osteogenic activity in the affected articulation,
identifying the origin of the pain and guiding intraintrarticular
injections.12,41,42
Osteochondral and chondral lesions
Fractures or lesions in one or both articular surfaces can be pro-
duced by shear, rotational or tangential forces generated by normal
articular movement. The traumatisms can lead to to fragments of
only cartilage (chondral fractures or lesions) or of cartilage and
underlying bone (osteochondral fractures or lesions). The fragment
separated from the articular surface can remain in situ, be slightly
displaced or remain free in the articular cavity.
Osteochondral lesions or defects of osteochondritis dissecans as a
result of acute or subacute lesions on the articular cartilage and the
adjacent subchondral bone are, in essence, considered as an osteo-
chondral fracture of an articular bone with or without separation
from the bone fragment. Although different etiopathogenic factors
have been suggested, at present, the possibiity of associated vas-
cular and traumatic factors is accepted, and it is believed that they
are the result of repeated microtraumas on the articulation asso-
ciated with focal aseptic necrosis in the subchondral bone which
is histopathologically observed.41 The age of onset of osteochon-
dritis dissecans varies, with a greater incidence in adolescence. The
most frequent localization is the femoral condyles, followed by the
astralagus (Fig.15), with other localizations including the hip, the
elbow and the shoulder.
The scintigraphic study allows diagnosis in the initial phases of
the process and the evaluation of the grade of healing, the evo-
lutive study or progression of the lesion and shows a focus of
radiotracer uptake in the subchondral bone of the articulation in
both the early and the delayed bone images.21 With the addition
of SPECT/CT, this metabolic information can be combined with
determination of the exact localization, morphology and size of the
osteochondral defect in the CT, being of prognostic and therapeu-
tic value. Although MR and CT demonstrate the morphology and
accurately assess the localization and the size of the lesion, they
do not determine the exact point of origin of the pain. This infor-
mation is provided by the scintigraphic study. Abnormal uptake of
the radiotracer is larger than the radiological bone fragment not-
ing active reparative osteogenic response. The differential diagnosis
of osteochondritis of femoral condyles should be established with
spontaneous or idiopathic osteonecrosis of the femoral condyle,
which is a process which should also be considered in acute knee
pain in middle aged or older athletes with normal radiographies,
with BS being more sensitive for detecting this lesion.
Osteochondritis dissecans of the astralagus should also be deter-
mined by scintigraphy of avascular necrosis of the astralagus. This
osteochondral fracture usually affects the dome of the astralagus
in the union of the upper and internal surfaces or of the upper
and external surfaces. Medial or internal osetochondral lesion of
the astralagar dome is the most common lesion, and in approxi-
mately 10% of the cases there may be bilateral lesions. Clinically,
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Fig. 16. Ossifying myositis in the intermediate vastus muslce of the right thigh in a football player after fibrillary rupture 2 months previously. (A) The delayed bone image
of the planar study shows an increase of uptake of the radiotracer in the middle third of the right thigh with an increase of vascularization in the early image (B). The
SPECT/CT study —maximum projection intensity images (C), selected corresponding coronal (D), right sagittal (E) and axial slices (F) of the CT and fusion SPECT/CT and 3D
reconstruction (G)— localize the metabolic bone activity in the heterotopic mass of muscle ossification in the CT image with cranial-caudal extension in the mediodistal third
of the intermediate vastus muscle, with the increase of osteogenic activity not being uniform with milder activity in the proximal half of the muscular ossification and more
intense and extense in the distal half.

the sportspersons affected are usually young adults who consult
for ankle pain of chronic evolution, although they may also report
a sensation of isolated instability or associated with pain. Acute
ankle sprains can be complicated with an osteochrondral lesion
in 6% of the cases, being more frequent in the medial astralagar
dome followed by the anterolateral dome. If the radiological study
is negative, BS is a good screening test in patients with chronic
post-sprain ankle pain.41,43 SPECT/CT is an excellent tool for the
diagnosis and management of osteochrondral lesions in any of their
localizations, with its main utility being for the evaluation of the
bone and the subchondral plaque. In addition, the CT image assesses
the presence of free or displaced fragments within the lesion or
instability of the fractured fragment, requiring surgery, and can
also be useful in post-surgical evaluation, especially when the MR
images are difficult to interpret.41 Some authors recommend the
combined use of SPECT/CT and MR, since together they can evaluate
the cartilage and the subchondral bone.43
a small increased focal uptake in the retropatellar facet can be
observed.8
Soft tissue and muscular lesions
The most adequate imaging techniques for the evaluation of soft
tissue lesions are ultrasonography and MR. However, scintigraphic
studies can demonstrate radiotracer uptake in soft tissue lesions,
especially in muscular lesions due to the concentration of the bone
radiotracer secondary to the presence of calcium deposits in the
lesioned muscular cells. Within the sports setting, muscular lesions
which show alterations in BS include ossifying myositis, stress-
induced rhabdomyolysis, intramuscular hematoma and fibrillary
rupture.
Ossifying myositis. Ectopic calcifications

Key point
Bone scintigraphy with SPECT/CT allows the diagnosis of
osteochrondral lesions in the initial phases and evaluation of their
evolutive stage, combining the metabolic information with the deter-
mination of the exact localization, morphology and size of the
osteochondral defect in the CT. These combined studies can also eval-
uate the presence of free bone fragments or instability of the fractured
fragment and the need for surgical intervention and are also useful for
post-surgical evaluation when the MR images are difficult to interpret.
Chondromalacia of the patella is a disease of the patellar hyaline
cartilage and within the sports context is considered a lesion caused
by overload. It is attributed to muscular weakness of the inter-
nal vastus or postural abnormalities such as flat feet and internal
torsion of the tibia. Although the diagnosis is basically histopatho-
logical and/or arthroscopic, scintigraphic studies show alterations
early. A global increase of activity in the patella (hot patella) or
Ectopic calcifications of the soft tissues usually occur in muscles,
tendons or ligaments with variable concentrations of the intensity
of the radiotracer. One of the principal applications of BS in mus-
cular disease is the detection of heterotopic muscular ossification
or ossifying myositis. This is generally procuded as a complication
following a traumatism in patients post-immobilization, after hip
surgery and in paraplegic patients and those with systemic pro-
cesses associated with ossification of soft tissues.
Scintigraphic studies show the vasculaization of the lesion and
the metabolic status of heterotopic bone formation, with very
active images in both the early and the delayed phases which
allow early diagnosis, delimitation of the extension of the lesion
and determination of the time at which bone neoformation ceases,
which is the optimal time to perform surgery.32 SPECT/CT can
define the extension of the mass of muscular ossification that is
metabolically active and anatomically localizes the muscle affected
(Fig. 16).
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Stress-induced rhabdomyolysis
This is an acute muscular lesion with alteration of the integrity
of the cellular membrane which can be produced after very intense
and severe exercise. Clinically it is manifested by diffuse or regional
pain and an elevation of muscular enzyme values. There is a direct
relationsip between muscle damage, the elevation of creatinine
kinase (even showing an increase of the myocardial band fraction)
and the sensation of pain in the athlete. Stress-induced rhabdomy-
olysis can be demonstrated in the BS with a mechanism of bone
radiotracer uptake similar to that observed in acute myocardial
infarction. The scintigraphic study is abnormal at a few hours
after exercise with maximum uptake of the radiotracer at 24−48 h,
showing a gradual decrease in activity until normalization one
week after the stress. The muscular groups presenting uptake of
the radiotracer correspond to the muscles that are overloaded in
each specific physical activity, and individualization of the muscles
affected allows the medical team to improve the biomechanics of
the athlete.21
Bursitis
Bursitis or inflammation of the synovial membrane localized
around the articulations and the bone prominences where the
muscles and tendons move around may be a cause of pain. Scinti-
graphically an increase of radiotracer uptake is observed in the
underlying bone. Trochanteric bursitis is one of the most common
lesions of the soft tissues of the hip region, and although it most fre-
quently occurs in middle aged and obese patients, it can be found in
athletes of all ages, often in association with degenerative arthropa-
thy in the lumbar rachis. Radiographies are usually normal. The
scintigraphic pattern is characteristic, with an increase in radio-
tracer uptake of variable intensity in the shape of a curved band in
the upper and lateral zone of the trochanter major,14 which may be
accurately localized in SPECT/CT images, leading to identification of
the origin of bone pain and ruling out other causes of pain in the
hip, such as fracture.
Final considerations
The role and diagnostic efficacy of BS studies is clearly estab-
lished in the evaluation of musculoskeletal lesions related to the
practice of sports. This imaging technique has ideal characteristics
for early detection of the most initial manifestations of dynamic
bone response to the lesion, reflecting its physiopathology and indi-
cating the etiological relationship between the focus of increased
metabolic bone activity and the symptomatology of the athlete. The
addition of hybrid SPECT/CT studies to BS has represented a revo-
lution in the imaging of these lesions. These studies significantly
increase the diagnostic reliability and their value in clinical prac-
tice, providing an increase in the sensitivity and especially of the
diagnostic specificity with the integration of physiological and mor-
phological information and accurate localization of the lesion. All of
this information allows early implementation of adequate therapy
and better therapeutic planning, thereby avoiding the progresion
of a more severe lesion or the appearance of complications, which
is an especially fundamental aspect in highly competitive athletes.
An essential previous requisite for correct interpretation of the
studies is the obtainment of technically demanding images, with 2-
or 3-phase BS being mandatory, taking into account the spectrum of
possible lesions which can affect the bone and soft tissues or both. It
is fundamental to insist on the importance of knowledge of the clin-
ical data, the physiopathology of sports lesions and their lesional
mechanisms. This knowledge, together with the evaluation of func-
tional/morphologic fusion images in the SPECT/CT and knowledge
of the scintigraphic patterns of the lesions, allows a more accu-
21
rate diagnosis of different musculoskeletal pathologies to be made.
In this sense, the exact correlation between the symptoms of the
athlete and the image is very important since many athletes have
abnormalities in more than one localization. This correlation will
faciltate determining which of these abnormalities are clinically
significant, and the possibility of interaction with the clinician is of
great value for achieving the final diagnosis.
Within the context of sports and from a practical point of view,
BS with the addition of SPECT/CT constitutes an excellent diagnos-
tic tool. The principal clinical applications are the early diagnosis of
occult fractures, evaluation of complications in the healing of frac-
tures, the detection of multiple or non suspected bone lesions, and
the possibility of performing whole body studies which can deter-
mine the cause of pain reported. In addition, it has an essential role
in the early diagnosis of bone stress lesions and in the evaluation of
enthesopathies. It is necessary to emphasize the importance of the
localization of a bone stress lesions which can classify the lesions
as high or low risk fractures since excessive treatment of lesions
considered to be of low risk may lead to deconditioning and unnec-
essary loss of training and competition period for the athlete, which
is especially important for elite athletes. To the contrary, recogni-
tion of high risk fractures is fundamental to avoid complications
which could place the career of the athlete at risk.
Likewise, the utility of BS studies should be highlighted in the
evaluation of the metabolic activity of any lesion that is or is not
already diagnosed. This imaging technique provides information
on the age of the lesion and in the evaluation of tear bone lesions,
articular impingement, chondral and osteochondral lesions and
potentially painful lesions in accessory bones. SPECT/CT is an excel-
lent technique for evaluating the cause of pain that etiologically
relates the metabolic activity in the ossicle, determining its clinical
significance.
Conflict of interests
The author declares no conflict of interests.
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