Diagnosis and management of bone stress injuries of the lower limb in athletesBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2511 (Published 24 April 2012) Cite this as: BMJ 2012;344:e2511
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The article by Pegrum et al1 on the diagnosis and management of bone stress injuries of the lower limbs in athletes gives an incorrect impression of the use of radionuclide bone imaging in this condition. Bone scanning is not only sensitive for stress fractures, as the authors state, but is also in a three phase study able to tell how recent it is. Dynamic, blood pool and 3 hour images positive means very recent; blood pool and 3 hour image positive means recent; and only the 3 hour image positive means less recent. This is particularly important in athletic jumpers who may have a mixture of old and new stress fractures. The authors claim that it is not specific because increased uptake is seen in bony infection, inflammatory joint conditions and cancer. No Nuclear Medicine Physician or Radiologist would confuse these conditions with a stress fracture. Bone infection does not give a linear or focal increase in uptake in a long bone; joint conditions are irrelevant as the authors state stress fractures in athletes usually occur in the shafts of bones not joints; and bone cancer gives an entirely different picture to a stress fracture. Bone scanning also allows the imaging and timing of ‘Shin Splints’ a common differential diagnosis.
They point out that there is radiation dose, but fail to point out that this (c.5 - 6mSv) is only between two and three times the annual background radiation burden in London and about half of that in Cornwall and parts of Scotland. In my understanding no morbidity or adverse effects of radiation have been recorded in young adults receiving less than 50mSv and the ‘Linear Hypothesis’ on which radiation protection is based is unproven below 100mSv.
They fail to point out that MRI is about four times as expensive as a bone scan.
Radionuclide bone imaging is a straightforward, highly sensitive and often specific cost effective approach to the diagnosis of stress fractures.
1. Pegrum J, Crisp T, Padhiar. Diagnosis and management of bone stress injuries of the lower limb in athletes. BMJ 2012; 344:35-40.
Competing interests: No competing interests