The Diagnosis of Stress Fractures in Athletes

Martin D. Devereaux, MB, BS; Graham R. Parr; Sylvia M. Lachmann, MA, ChB;
Peter Page-Thomas, MB, BS; Brian L. Hazleman, MA, MB

Eighteen patients with shin pain that was clinically considered to be "shin splints," anterior tibial com¬
caused by stress fracture of the tibia or fibula underwent radiological,
a partment syndrome, and tibialis ante¬
thermographic, and scintigraphic studies and a test of ultrasound-induced rior tendinitis can be confused clini¬
pain. When initially seen, 15 had stress fractures confirmed by scintigraphy. cally with stress fractures of the
Of these, 12 had abnormal thermograms, eight had positive test results for lower part of the leg. If these soft-
ultrasound-induced pain, and seven had abnormal radiographs. Thermogra- tissue problems can be accurately
phy used alone seemed to be a safe, rapid means of diagnosis for stress separated from a stress fracture,
fractures in the tibia or fibula and was not found to be related to symptom their response to appropriate therapy
duration. In the radiologically normal group of stress fractures, four (50%) is usually rapid. An accurate diagno¬
had positive test results for ultrasound stress tests and normal thermograms. sis will also prevent the unnecessarily
The combination of these two tests should provide an early method of long rest from sports that would be
detecting stress fractures in the tibia and fibula, thereby avoiding scintiscans advised if the initial diagnosis of
in some athletes. stress fracture had been incorrect.
(JAMA 1984;252:531-533) This study was undertaken to eval¬
uate the accuracy of thermography
ORA VA1 has found that stress frac¬ Bone scintigraphy can detect stress and ultrasound-induced pain tests in
tures of the tibia or fibula occurred in fractures much earlier than radiolo¬ the diagnosis of stress fractures in
1.1% of athletes attending the Sports gy.5 Scintigraphy is expensive, time athletes. Both methods were to be
Injury Clinic. In one study of athletes consuming, and requires the use of a assessed in an attempt to find a rapid,
it contributed to 19% of exertional radioactive label. Thermography has safe, and inexpensive means of con¬
pains in the lower part of the leg.2 been used to detect the heat emission firming stress fractures.
Unless recognized, the continually from the area of vascular hyperactivi-
Methods
recurring pain can result in the cessa¬ ty surrounding a callus.6 Recently, a
tion of all sporting activity. Stress test of ultrasound-induced pain has Athletes attending the Sports Injury
fractures are demonstrated radiologi- been described as an effective means Clinic were admitted to the study if they
had the following symptoms and signs: (1)
cally by a localized periosteal reac¬ of detecting the damaged periosteum
pain in the lower part of the leg occurring
tion, endosteal thickening, or a radio- in early stress fractures.7 These latter
during and after sporting activity, but
lucent line extending through at least two techniques have the advantages gradually resolving with rest, only to recur
one cortex.3 Unfortunately, these of being rapid and noninvasive. on resumption of activity; and (2) a local¬
changes may not be visible until up to Because for athletes a six- to ten- ized area of tenderness with or without
three weeks after the onset of symp¬ week rest from sports is the only swelling over the tibia or fibula. Radio¬
toms,4 thus limiting the usefulness of effective treatment resulting in reso¬ graphs, thermograms, scintiscans, and an
radiology in the diagnosis of stress lution of the bony damage, a definite ultrasound stress test were performed on
fractures. diagnosis is necessary to allow an all patients suspected of having a stress
fracture with these criteria.
early return to sporting activity. The A thermovision system was used with
definite diagnosis of a stress fracture
From the Sports Injury Clinic (Drs Devereaux and an interface to record the thermograms on
is required in these athletes to pre¬
Lachmann), and the Rheumatology Research Unit magnetic tape as a digital image for later
(Drs Page-Thomas and Hazleman and Mr Parr), vent a continuation of sports that
Addenbrooke's Hospital, Cambridge, England.
analysis. Thermograms were taken with
may result in slow healing or the the patient seated after 15 minutes' stabil¬
Reprint requests to Sports Injury Clinic, Unit E6,
Addenbrooke's Hospital, Hills Road, Cambridge, development of a complete fracture.8 ization at 20 °C and at a distance of 1 m
England CB2 2QQ (Dr Devereaux). Other causes of shin pain such as from the camera. The anterior aspect of

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 Table 1.—Athletes With Normal Scintiscans

Duration Ultrasound-
Site ofPain, wk Induced Pain Tests* Thermograms" Radiographs'
Lower part of the fibula 5
Lower part of the fibula 3
Lower part of the tibia 1
•
Pluses indicate abnormal test results; minuses, normal test results.

Table 2.—Athletes With Abnormal Scintiscans

Ultrasound-
Duration Induced Pain
Site of Pain, wk Tests' Thermograms' Radiographs'
Upper part of tibia +
Upper part of tibia +
Upper part of tibia + +
Upper part of tibia +
Upper part of tibia + + +
Middle part of tibia + +
Middle part of tibia + +
Lower part of fibula
Lower part of fibula + +
Lower part of fibula + +
Lower part of fibula + +
Lower part of fibula + +
Lower part of fibula + +
Lower part of fibula +
Lower part of fibula

'Pluses indicate abnormal test results; minuses, normal test results.

clinically normal leg showed no ferential diagnosis includes stress

Top, Stress fracture of lower part of left fibula.
Center, Stress fracture of upper part of left
tibia. Bottom, Stress fracture of middle part of
left tibia. Figures illustrated use a seven-color
code from blue to white, increasing in temper¬
ature at 0.7 °C increments. Circular calibra¬
tion marker is a hot body fixed at 31 °C.
both shins was viewed in each patient.
Ultrasound stress tests were performed
by a physiotherapist using the method
described by Moss and Mowat.' Radio¬
graphs were read by members of the
radiology department. Radionuclide im¬
ages using technetium Tc 99m etidronate
were read by a nuclear medicine physi¬
cian.
Results
Eighteen consecutive athletes (11
men; mean age, 23 years; range, 18 to
37 years) attending the Sports Injury
Clinic with symptoms and signs of a
stress fracture of the tibia or fibula
were included in the study. Fifteen
were running injuries and the others
injuries were related either to jog¬
ging, ballet, or soccer. Three of the 18
athletes had normal roentgenograms
and scintiscans. At the time of follow-
up they were considered not to have a
stress fracture. In all 18 patients the
abnormality on any of the diagnostic
tests used.
Table 1 demonstrates that the
three athletes with normal scinti¬
scans had a positive ultrasound stress
test result, while their thermograms
were normal. This resulted in three
(8.3%) false-positives in 36 tests for
ultrasound-induced pain. Of the 15
athletes with stress fractures (Table
2) eight (53%) patients had a positive
ultrasound test result and 12 (80%)
patients had abnormal thermograms
(Figure).
In six of the eight radiologically
negative stress fractures thermo¬
grams proved abnormal. In four of
these patients, test results for ultra¬
sound-induced pain were also posi¬
tive. In the ultrasound-positive group
the mean duration was 2.9 weeks
(range, one to six
weeks) compared
with 4.3 weeks (range, one to eight
weeks) in the negative group. There
was no difference in the duration of
symptoms for patients with normal
thermograms and those with abnor¬
mal thermograms.
Comment
Athletes with shin pain present a
difficult diagnostic problem. The dif-
fractures, compartment syndromes,
and tenosynovitis. Any investigations
must be preceded by a careful clinical
examination. The soft-tissue causes of
shin pain can usually be diagnosed
clinically by signs such as fine crepi-
tus over a tibialis anterior tendinitis
and bilateral tenderness over the low¬
er two thirds of the medial-tibial
border in shin splints. Classically, the
localized tenderness of a stress frac¬
ture can be differentiated from these
conditions. This is not always so clear
in the clinical situation. On clinical
examination alone, all of the 18 ath¬
letes who entered this study were
considered to have stress fractures.
On scintiscans the diagnosis was
proved to be correct in only 15 of
these athletes. Thermograms were
abnormal in 80% of the confirmed
stress fractures. Stress fractures
could also be differentiated by ther¬
mographie pattern from the other
causes of shin pain.
Devas9 reported that most stress
fractures of the tibia are posterome-
dial. Because of overlying muscle,
Meurman et al* encountered difficulty
in the thermographie diagnosis of
these lesions. It can be noted from
Table 2 that there was no difference

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 in the positive diagnosis of stress
fracture in either the tibia or fibula.
With a period of adequate cooling this
difficulty has been overcome, al¬
lowing the thermogram to detect the
increased blood-flow heat associated
with the stress fracture.
This study does not confirm the
success previously reported with
using ultrasound-induced pain test in
the diagnosis of stress fractures.7 It
does, however, verify the observation
that ultrasound-induced pain in frac¬
tures decreases with time."0 This is
believed to be caused by the decrease
in heat production by ultrasound
energy on the periosteum involved in
substantial callus formation.
Thermographie techniques proved
to besuperior because the duration of
pain symptoms did not affect the
abnormal results. The addition of
ultrasound-induced pain test to ther¬
mographie techniques was of assist-
anee in 50% of radiologically negative
stress fractures. Thermograms alone
were abnormal in 75% of these
patients. Both thermograms and ul¬
trasound-induced pain were more
sensitive than radiographs in the
diagnosis of stress fractures, however
the ultrasound-induced pain test
lacked the specificity found with the
other two tests. Both of these meth¬
ods are valuable noninvasive tests for
the diagnosis of stress fractures.
With their combined use in radiologi¬
cally normal athletes with shin pain,
the need for confirmation through the
use of scintigraphy should be re¬
duced.
The Sports Injury Clinic is supported by
grants from the Peter Wilson Memorial Fund of
the Daily Mirror, and the Colleges and Universi¬
ty of Cambridge, Cambridge, England. The
Rheumatology Research Unit is supported by
the Arthritis and Rheumatism Council. GEMS
Computers, Cambridge, England, loaned the
equipment used to produce the figures.
References
1. Orava S: Stress fractures. Br J Sports Med
1980;14:40-44.
2. Orava S, Puranen J: Athletes' leg pains. Br
J Sports Med 1979;13:92-97.
3. Geslien GE, Thrall JH, Espinosa JL, et al:
Early detection of stress fractures using 99m Tc
polyphosphate. Radiology 1976;121:683-687.
4. Hallel T, Amit S, Segal D: Fatigue fractures
of tibial and femoral shaft in soldiers. Clin
Orthop 1976;118:35-43.
5. Prather JL, Nusynowitz ML, Snowdy HA, et
al: Scintigraphic findings in stress fractures. J
Bone Joint Surg Am 1977;59:869-874.
6. Meurman K, Somer K, Sjovall J: Thermog-
raphy of stress fractures in military personnel.
Acta Thermographica 1980;5:132-136.
7. Moss A, Mowat AG: Ultrasonic assessment
of stress fractures. Br Med J 1983;286:1479\x=req-\
1480.
8. Marty R, Denney JD, McKamey MR, et al:
Bone trauma and related benign disease assess-
ment by bone scanning. Semin Nucl Med 1976;
6:107-120.
9. Devas MB: Stress fractures of the tibia in
athletes or 'shin soreness.' J Bone Joint Surg Br
1958;40:227-239.
10. Bedford AF, Glasgow MM, Wilson JN:
Ultrasound assessment of fractures and its use
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Transmission of Herpes Simplex Virus

Type 1 Infection in Rugby Players
William B. White, MD, Jane M. Grant-Kels, MD

Skin infections, both bacterial and viral, are endemic in contact sports the sides of the face, chin, neck, and
such as wrestling and rugby football. In this report, we describe four cases of upper part of the back in those
extensive cutaneous herpes simplex virus in players on a rugby team. All patients, it is thought that the virus
players had a prodrome of fever, malaise, and anorexia with a weight loss of gains access to the host through abra¬
3.6 to 9.0 kg. Two players experienced ocular lesions associated with sions or breaks in the skin when the
cutaneous vesicular lesions of the face. A third player, who had herpetic wrestlers are in the "locking-up"
lesions on his lower extremity, experienced paresthesias, weakness, and position.
intermittent urinary retention and constipation. All infected players on the Herpetic skin lesions have recently
team were forwards or members of the "scrum," which suggests a been reported in rugby forwards in
field-acquired infection analogous to the herpetic infections seen in wres- England56 and South Africa,' coun¬
tlers (herpes gladiatorum). Considering the serious sequelae of recurrent tries where rugby football is a major
herpes simplex keratitis, the traumatic skin lesions in rugby football players contact sport. Rugby football has
should be cultured for herpes virus, and infected individuals should be become increasingly popular in the
restricted from playing until crusted lesions have disappeared. United States and we have recently
(JAMA 1984;252:533-535) noted an outbreak of HSV type 1
infection on an American rugby team.
PRIMARY skin infections with None of the players had a previous
From the Department of Internal Medicine (Dr
White), and Division of Dermatology (Dr Grant-Kels), herpes simplex virus (HSV) associ¬ history of herpes labialis or genital
Department of Medicine, University of Connecticut ated with the trauma sustained in herpes. The cutaneous appearance
School of Medicine, Farmington. contact sports have been reported in and location of the lesions and subse¬
Reprint requests to Room L-2071A, University of
Connecticut Health Center, Farmington, CT 06032 college wrestlers.1'4 Because of the quent ocular and neurologic complica¬
(Dr White). unusual locale of herpetic lesions on tions that developed were severe and

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