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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Matcuk GR Jr, Mahanty SR, Skalski MR, Patel DB, White EA, Gottsegen CJ. Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. [Review]. Emergency Radiology. 23(4):365-75, 2016 Aug.EMERG. RADIOL.. 23(4):365-75, 2016 Aug. Review/Other-Dx N/A To review the pathophysiology, clinical presentation, imaging features and treatment options for stress fractures. No results stated in abstract. 4
2. Aparisi Gomez MP.. Nonspinal Fragility Fractures. [Review]. Semin Musculoskelet Radiol. 20(4):330-344, 2016 Sep. Review/Other-Dx N/A To review the clinical and diagnostic aspects of nonspinal fragility fractures. No results stated in abstract. 4
3. Abbott A, Bird M, Brown SM, Wild E, Stewart G, Mulcahey MK. Part II: presentation, diagnosis, classification, treatment, and prevention of stress fractures in female athletes. [Review]. Phys Sportsmed. 48(1):25-32, 2020 02. Review/Other-Dx N/A To review the presentation, diagnosis, classification, treatment, and prevention of SFx in female athletes. A thorough history, physical exam, and appropriate imaging can facilitate early diagnosis of stress fracture (SFx) and faster resolution of symptoms with more conservative management. The female athlete triad is an especially important factor that contributes to the increased risk of SFx in females. The continuum of stress injuries ranges from mild microfailure to complete fracture, which has resulted in the development of newer grading schemas through MRI and radiographic findings. Stress fractures are also classified as low- or high-risk according to anatomic location, as blood supply and applied forces at different locations affect the likelihood of fracture propagation, displacement, delayed union, or non-union.Conclusions: The ability to screen for at-risk athletes is paramount in preventing SFx. Recognition and prompt treatment of the female athlete triad requires a multidisciplinary approach in order to restore energy balance, correct menstrual irregularities, and improve bone health. 4
4. Knapik JJ, Reynolds K, Hoedebecke KL. Stress Fractures: Etiology, Epidemiology, Diagnosis, Treatment, and Prevention. J Spec Oper Med. 17(2):120-130, Summer 2017. Review/Other-Dx N/A To detail the etiology, epidemiology, diagnosis, treatment and prevention of stress fractures. No results stated in abstract. 4
5. Saunier J, Chapurlat R. Stress fracture in athletes. [Review]. Joint Bone Spine. 85(3):307-310, 2018 05. Review/Other-Dx N/A To review stress fractures in athletes. No results stated in abstract. 4
6. Tenforde AS, Carlson JL, Chang A, et al. Association of the Female Athlete Triad Risk Assessment Stratification to the Development of Bone Stress Injuries in Collegiate Athletes. Am J Sports Med. 45(2):302-310, 2017 Feb. Observational-Dx 239 patients To classify athletes from a collegiate population of 16 sports into low-, moderate-, and high-risk categories using the Female Athlete Triad Cumulative Risk Assessment score and (2) evaluate the predictive value of the risk categories for subsequent BSIs. Of 239 athletes, 61 (25.5%) were classified into moderate-risk and 9 (3.8%) into high-risk categories. Sports with the highest proportion of athletes assigned to the moderate- and high-risk categories included gymnastics (56.3%), lacrosse (50%), cross-country (48.9%), swimming/diving (42.9%), sailing (33%), and volleyball (33%). Twenty-five athletes (10.5%) assigned to risk categories sustained >/=1 BSI. Cross-country runners contributed the majority of BSIs (16; 64%). After adjusting for age and participation in cross-country, we found that moderate-risk athletes were twice as likely as low-risk athletes to sustain a BSI (risk ratio [RR], 2.6; 95% confidence interval [95% CI], 1.3-5.5) and high-risk athletes were nearly 4 times as likely (RR, 3.8; 95% CI, 1.8-8.0). When examining the 6 individual components of the triad risk assessment score, both the oligomenorrhea/amenorrhea score ( P = .0069) and the prior stress fracture/reaction score ( P = .0315) were identified as independent predictors for subsequent BSIs (after adjusting for cross-country participation and age). 4
7. DeFroda SF, Cameron KL, Posner M, Kriz PK, Owens BD. Bone Stress Injuries in the Military: Diagnosis, Management, and Prevention. [Review]. Am J Orthop. 46(4):176-183, 2017 Jul/Aug. Review/Other-Dx N/A To review the diagnosis, management, and prevention of bone stress injuries with a focus on more serious manifestations, such as stress fracture. No results stated in abstract. 4
8. Hayashi D, Jarraya M, Engebretsen L, et al. Epidemiology of imaging-detected bone stress injuries in athletes participating in the Rio de Janeiro 2016 Summer Olympics. BJSM online. 52(7):470-474, 2018 Apr. Observational-Dx 11274 patients To describe the demographics, frequency and anatomical location of stress injuries (ie, stress reaction and stress fractures) in athletes at the Rio de Janeiro 2016 Summer Olympic Games. Imaging revealed 9 stress fractures (36%) and 16 stress reactions (64%) in 18 female and 7 male athletes (median age 25 years, age range 18-32). Stress injuries were mostly in the lower extremities (84%), particularly tibia (44%) and metatarsals (12%), with two in the lumbar spine (8%). Stress injuries were most common in track and field athletes (44%) followed by volleyball players (16%), gymnastics (artistic) (12%) and other type of sports. 4
9. Lambert BS, Cain MT, Heimdal T, et al. Physiological Parameters of Bone Health in Elite Ballet Dancers. Med Sci Sports Exerc. 52(8):1668-1678, 2020 08. Review/Other-Dx 112 patients To characterize bone health in relation to stress fracture history, body composition, eating disorder risk, and blood biomarkers in professional male and female ballet dancers. Female dancers demonstrated reduced spinal (42nd percentile, 10%T < -1) and pelvic (16th percentile, 76%T < -1) BMD. Several anthropometric measures were predictive of BMD (P < 0.05, r = 0.65-0.81, standard error of estimate = 0.08-0.10 g.cm, percent error = 6.3-8.5). Those scoring >1 on EAT26 had lower BMD than did those with a score of 0-1 (P < 0.05). 4
10. Bazire L, Xu H, Foy JP, et al. Pelvic insufficiency fracture (PIF) incidence in patients treated with intensity-modulated radiation therapy (IMRT) for gynaecological or anal cancer: single-institution experience and review of the literature. [Review]. Br J Radiol. 90(1073):20160885, 2017 May. Observational-Dx 341 patients To summarize the results of pelvic insufficiency fracture (PIF) incidence in patients with anal or gynaecological cancer treated by pelvic intensity-modulated radiation therapy (IMRT). 341 patients were treated by IMRT for gynaecological or anal cancer between 2007 and 2014. 15 patients experienced at least 1 pelvic fracture after external beam radiotherapy, corresponding to an overall incidence of 4.4%. Age and menopausal status were correlated with an increased fracture risk (p = 0.0274 and p < 0.0001, respectively). The site of the primary tumour (gynaecological or anal canal) was not associated with an excess fracture risk. The median maximum dose received at the fracture site was 50.3 Gy (range: 40.8-68.4 Gy). 4
11. Png MA, Mohan PC, Koh JSB, Howe CY, Howe TS. Natural history of incomplete atypical femoral fractures in patients after a prolonged and variable course of bisphosphonate therapy-a long-term radiological follow-up. Osteoporos Int. 30(12):2417-2428, 2019 Dec. Review/Other-Dx 76 patients To evaluate the natural history of lateral femoral stress fractures (FSF) by serial radiography over a variable period of time in a cohort of patients treated for some time with bisphosphonates for osteoporosis, whilst also identifying the fracture response in cases where bisphosphonates were discontinued. 66.5% FSF showed group stability between the first and last radiographs: group B (79.1%), group C (45.7%). 28.6% progressed, mostly following an ordered sequence starting from group A, progressing to B, then C, before culminating in D. Progression rate was as follows: A-100% (11/11), B-18.3% (21/115), C-40% (14/35). Regression in FSF was uncommon-5.6% (8/161). 34.8% (32/92) sustained displaced fractures. Kaplan-Meier analysis showed statistically significant difference between the groups; median survival (95% CI): A-4189 (-), B-3383.0 (-), C-1807 (0.0-3788.6) and progression to displaced fracture when bisphosphonate had been stopped for at least 6 months. The group without recent bisphosphonates had a lower group progression rate (17.1%, 12/70). Nevertheless, 10.9% (5/46) progressed to displaced fracture. This group also had the highest proportion of stable (77.1%, 54/70) and regressive lesions (5.7%, 4/70). 4
12. Sapienza LG, Salcedo MP, Ning MS, et al. Pelvic Insufficiency Fractures After External Beam Radiation Therapy for Gynecologic Cancers: A Meta-analysis and Meta-regression of 3929 Patients. Int J Radiat Oncol Biol Phys. 106(3):475-484, 2020 03 01. Meta-analysis 21 studies To estimate the overall rate, symptomatic proportion, and most common sites of pelvic insufficiency fracture (PIF) after external beam radiation therapy for gynecologic cancers based on posttreatment computed tomography, magnetic resonance imaging, positron emission tomography, or bone scintigraphy. Twenty-one studies met the inclusion criteria (total 3929 patients). Five hundred four patients developed PIF, translating to an overall rate of 14% (95% confidence interval, 10%-18%, based on 21 studies). Among these cases with PIF, the proportion of symptomatic patients was 61% (95% confidence interval, 52%-69%, based on 14 studies). The total number of PIFs was 704 (mean, 1.72 PIFs per each patient to develop PIF, based on 14 studies). More recent series (P = .0074) and the use of intensity modulated radiation therapy (P = .0299) were associated with lower fracture rates. The most common fracture sites were sacroiliac joint (39.7%), body of the sacrum (33.9%), pubis (13%), lumbar vertebra (7%), iliac bone (2.8%), acetabulum (2.1%), and femoral head/neck (1.5%). The median time to fracture was 7.1 to 19 months after radiation therapy. Good
13. Arendt E, Agel J, Heikes C, Griffiths H. Stress injuries to bone in college athletes: a retrospective review of experience at a single institution. Am J Sports Med 2003;31:959-68. Review/Other-Dx 74 patients To review, in a college athlete population, the epidemiologic aspects of stress injuries to bone, and to examine a subset of patients who were treated with a uniform protocol for return to activities, with magnetic resonance imaging as the primary tool for diagnosis. Seventy-four athletes had lower extremity symptoms consistent with stress injury to bone. Diagnosis was confirmed in 68 of these athletes, 61 via magnetic resonance imaging, 6 via positive radiographs only, and 1 via bone scan only. Distance runners accounted for the most stress injuries to bone for both men and women. The tibia (37%) was the most frequently involved bone; however, as an anatomic region, the foot (44%) was the site of the most stress injuries. There was a significant correlation between grade of injury and time to full return to activity. 4
14. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med 1987;15:46-58. Review/Other-Dx 320 patients To provide descriptive data from 320 cases of bone scan-positive stress fractures in athletes and to document the results of conservative treatment. The most common bone injured was the tibia (49.1%), followed by the tarsals (25.3%), metatarsals (8.8%), femur (7.2%), fibula (6.6%), pelvis (1.6%), sesamoids (0.9%), and spine (0.6%). Stress fractures were bilateral in 16.6% of cases. A significant age difference among the sites was found, with femoral and tarsal stress fractures occurring in the oldest, and fibular and tibial stress fractures in the youngest. Running was the most common sport at the time of injury but there was no significant difference in weekly running mileage and affected sites. A history of trauma was significantly more common in the tarsal bones. The average time to diagnosis was 13.4 weeks (range, 1 to 78) and the average time to recovery was 12.8 weeks (range, 2 to 96). Tarsal stress fractures took the longest time to diagnose and recover. Varus alignment was found frequently, but there was no significant difference among the fracture sites, and varus alignment did not affect time to diagnosis or recovery. Radiographs were taken in 43.4% of cases at the time of presentation but were abnormal in only 9.8%. A group of bone scan-positive stress fractures of the tibia, fibula, and metatarsals (N = 206) was compared to a group of clinically diagnosed stress fractures of the same bone groups (N = 180), and no significant differences were found. 4
15. Niva MH, Sormaala MJ, Kiuru MJ, Haataja R, Ahovuo JA, Pihlajamaki HK. Bone stress injuries of the ankle and foot: an 86-month magnetic resonance imaging-based study of physically active young adults. Am J Sports Med. 35(4):643-9, 2007 Apr. Review/Other-Dx 378 bone stress injuries in 142 ankles and feet imaged To assess incidence, location, and type of bone stress injuries of the ankle and foot in military conscripts with ankle and/or foot pain using MRI. Incidence is 126 per 100,000 person-years. This incidence represents the stress injuries not diagnosable with radiographs and requiring magnetic resonance images. Of injuries, 57.7% occurred in the tarsal and 35.7% in the metatarsal bones. Multiple bone stress injuries in one foot were found in 63% of the cases. The calcaneus and fifth metatarsal bone were usually affected alone. Injuries to the other bones of the foot were usually associated with at least one other stress injury. The talus and calcaneus were the most commonly affected single bones. High-grade bone stress injury (grade IV-V) with a fracture line on magnetic resonance images occurred in 12% (talus, calcaneus), and low-grade injury (grade I-III) presented only as edema in 88% of the cases. 4
16. Tamaki Y, Nagamachi A, Inoue K, et al. Incidence and clinical features of sacral insufficiency fracture in the emergency department. Am J Emerg Med. 35(9):1314-1316, 2017 Sep. Observational-Dx 250 patients To  clarify the incidence and clinical features of SIF as well as the characteristic findings on magnetic resonance imaging (MRI) of the lumbar spine. We detected 11 cases of SIF. Initial symptoms of SIF were low back pain (36.4%), gluteal pain (63.6%), and coxalgia (18.2%). Two patients complained of both low back pain and gluteal pain. The mean delay between the first visit and an accurate diagnosis of SIF was 23.9days. This time interval was significantly longer than in patients with other types of pelvic fracture. Four patients underwent MRI targeting the lumbar spine to investigate their symptoms. In all 4 patients, the signal intensity on T1-weighted and fat-suppressed images of the second sacral segment was low and high, respectively. 4
17. Dobrindt O, Hoffmeyer B, Ruf J, et al. Blinded-read of bone scintigraphy: the impact on diagnosis and healing time for stress injuries with emphasis on the foot. Clin Nucl Med. 36(3):186-91, 2011 Mar. Observational-Dx 84 patients To evaluate the use of bone scintigraphy (BS) for the diagnosis of stress fractures in athletes and its validity for the prediction of healing time, with a focus on foot injuries. For the diagnosis of stress injuries (n = 50/93), mean sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 97.3%, 67.4%, 77.7%, 95.6%, and 83.5%, respectively. Interobserver analysis showed a high agreement between all 3 readers (mean kappa = 0.83). In univariate analysis healing time of grade 3 to 4 stress injuries was significantly higher (median, 87 days; interquartile range, 69-132 days) compared with grade 1 to 2 lesions (median, 63 days; interquartile range, 43-95 days; P = 0.0067). Moreover, healing time of scintigraphic high grade stress injuries was significantly longer in a general linear model with adjustment for cofactors (grade, 3-4 vs. 1-2; P = 0.033). 2
18. Bryant LR, Song WS, Banks KP, Bui-Mansfield LT, Bradley YC. Comparison of planar scintigraphy alone and with SPECT for the initial evaluation of femoral neck stress fracture. AJR Am J Roentgenol. 2008;191(4):1010-1015. Observational-Dx 38 patients had planar scintigraphy and 33 patients had planar scintigraphy and SPECT before MRI Retrospective study to compare the accuracy of planar scintigraphy alone versus planar scintigraphy with SPECT for the initial evaluation of femoral neck stress fractures in a young military population. The sensitivities of planar scintigraphy alone and with SPECT were 50% and 92.3%, respectively (P=0.03). Accuracy of each technique for the detection of high-grade fractures was 12.5% and 70%, respectively (P=0.025). Results suggest that SPECT should be performed with planar bone scintigraphy for the evaluation of patients with suspected femoral neck stress fractures. 3
19. McCormick F, Nwachukwu BU, Provencher MT. Stress fractures in runners. Clin Sports Med. 2012;31(2):291-306. Review/Other-Dx N/A To review the pathophysiology, risk factors, diagnosis, treatment, and prevention of stress fractures in runners. Stress fractures are a relatively common entity in athletes, in particular, runners. Physicians and health care providers should maintain a high index of suspicion for stress fractures in runners presenting with insidious onset of focal bone tenderness associated with recent changes in training intensity or regimen. It is particularly important to recognize “high-risk” fractures, as these are associated with an increased risk of complication. A patient with confirmed radiographic evidence of a high-risk stress fracture should be evaluated by an orthopedic surgeon. Runners may benefit from orthotics, cushioned sneakers, interval training, and vitamin/calcium supplementation as a means of stress fracture prevention. 4
20. Tokumaru S, Toita T, Oguchi M, et al. Insufficiency fractures after pelvic radiation therapy for uterine cervical cancer: an analysis of subjects in a prospective multi-institutional trial, and cooperative study of the Japan Radiation Oncology Group (JAROG) and Japanese Radiation Oncology Study Group (JROSG). Int J Radiat Oncol Biol Phys. 2012;84(2):e195-200. Review/Other-Dx 59 patients To investigate pelvic insufficiency fractures (IF) after definitive pelvic radiation therapy for early-stage uterine cervical cancer, by analyzing subjects of a prospective, multi-institutional study. The median follow-up was 24 months. The 2-year pelvic IF cumulative occurrence rate was 36.9% (21 patients). Using Common Terminology Criteria for Adverse Events version 3.0, grade 1, 2, and 3 IF were seen in 12 (21%), 6 (10%), and 3 patients (5%), respectively. Sixteen patients had multiple fractures, so IF were identified at 44 sites. The pelvic IF were frequently seen at the sacroileal joints (32 sites, 72%). Nine patients complained of pain. All patients' pains were palliated by rest or non-narcotic analgesic drugs. Higher age (>70 years) and low body weight (<50 kg) were thought to be risk factors for pelvic IF (P=.007 and P=.013, Cox hazard test). 4
21. Williams TR, Puckett ML, Denison G, Shin AY, Gorman JD. Acetabular stress fractures in military endurance athletes and recruits: incidence and MRI and scintigraphic findings. Skeletal Radiol. 2002;31(5):277-281. Review/Other-Dx 178 patients To evaluate the incidence and the MRI and scintigraphic appearance of acetabular stress (fatigue) fractures in military endurance athletes and recruits. Stress fractures are common in endurance athletes and in military populations; however, stress fracture of the acetabulum is uncommon. Twelve of 178 patients (6.7%) in our study had imaging findings consistent with acetabular stress fractures. Two patterns were identified. Seven of the 12 (58%) patients had acetabular roof stress fractures. In this group, two cases of bilateral acetabular roof stress fractures were identified, one with a synchronous tensile sided femoral neck stress fracture. The remaining five of 12 (42%) patients had anterior column stress fractures, rarely occurring in isolation, and almost always occurring with inferior pubic ramus stress fracture (4 of 5, or 80%). One case of bilateral anterior column stress fractures was identified without additional sites of injury. 4
22. Muthukumar T, Butt SH, Cassar-Pullicino VN. Stress fractures and related disorders in foot and ankle: plain films, scintigraphy, CT, and MR Imaging. [Review] [139 refs]. Semin Musculoskelet Radiol. 9(3):210-26, 2005 Sep. Review/Other-Dx N/A To review the various diagnostic imaging techniques in evaluating patients with suspected stress fractures. MRI is the new “gold standard” and the modality of choice in evaluating for early stress injury. 4
23. Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 235(2):553-61, 2005 May. Observational-Dx 42 patients;10 volunteers To prospectively compare CT, MRI, and bone scintigraphy in athletes with clinically suspected early stress injury of tibia. Sensitivity of MRI, CT, and bone scintigraphy was 88%, 42%, and 74%, respectively. Specificity, accuracy, and PPVs and NPVs were 100%, 90%, 100%, and 62%, respectively, for MRI and 100%, 52%, 100%, and 26%, respectively, for CT. Significant difference in detection of early tibial stress injuries was found between MRI and both CT and bone scintigraphy (McNemar test; P<.001 and P=.008, respectively). MRI is the single best technique in assessment of patients with suspected tibial stress injuries; in some patients with negative MRI findings, CT can depict osteopenia, which is the earliest finding of fatigue cortical bone injury. 3
24. Wright AA, Hegedus EJ, Lenchik L, Kuhn KJ, Santiago L, Smoliga JM. Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: A Systematic Review With Evidence-Based Recommendations for Clinical Practice. Am J Sports Med 2016;44:255-63. Review/Other-Dx 21 studies To determine the diagnostic accuracy statistics of imaging modalities used to diagnose lower extremity stress fractures and to synthesize evidence-based recommendations for clinical practice. Reported sensitivity and specificity (95% CI) were as follows: For conventional radiography, sensitivity ranged from 12% (0%-29%) to 56% (39%-72%) and specificity ranged from 88% (55%-100%) to 96% (87%-100%). For nuclear scintigraphy (NS), sensitivity ranged from 50% (23%-77%) to 97% (90%-100%) and specificity from 33% (12%-53%) to 98% (93%-100%). For magnetic resonance imaging (MRI), sensitivity ranged from 68% (45%-90%) to 99% (95%-100%) and specificity from 4% (0%-11%) to 97% (88%-100%). For computed tomography, sensitivity ranged from 32% (8%-57%) to 38% (16%-59%) and specificity from 88% (55%-100%) to 98% (91%-100%). For ultrasound, sensitivity ranged from 43% (26%-61%) to 99% (95%-100%) and specificity from 13% (0%-45%) to 79% (61%-96%). 4
25. Hatem SF, Recht MP, Profitt B. MRI of Little Leaguer's shoulder. Skeletal Radiol. 2006;35(2):103-106. Review/Other-Dx 4 patients To describe MRI findings and review the literature of young baseball players with stress injury of the proximal humerus. MRI clearly shows the osseous and marrow changes in these patients with shoulder pain. 4
26. Liong SY, Whitehouse RW. Lower extremity and pelvic stress fractures in athletes. [Review]. Br J Radiol. 85(1016):1148-56, 2012 Aug. Review/Other-Dx N/A To review the incidence, presentation, radiological findings and management options for athletes with stress fractures of the lower limb. Stress fractures are relatively common in athletes, particularly in long-distance runners. Strong clinical suspicion in concert with radiological imaging (in the form of plain radiographs, MRI, CT or bone scan) play important roles in the detection of stress injuries in athletes. Early recognition and treatment of stress fractures reduce athletic morbidity and allow timely return to high-level activity. It is therefore important for radiologists to be aware of mechanisms leading to, and locations of, stress injuries, to facilitate timely diagnosis. 4
27. Oka M, Monu JU. Prevalence and patterns of occult hip fractures and mimics revealed by MRI. AJR Am J Roentgenol. 2004;182(2):283-288. Review/Other-Dx 73 patients To evaluate the patterns of injury seen on MRI that are difficult to diagnose on radiography. Forty-six percent (35/76) of the studies showed subtle fractures. Seventeen fractures were in the proximal femur and 18 in the innominate bone. Soft-tissue abnormalities were common, found in 65% of the studies. Twenty percent of the MRI findings were considered normal because there was no apparent finding on the images to explain the patients' symptoms. 4
28. Sankey RA, Turner J, Lee J, Healy J, Gibbons CE. The use of MRI to detect occult fractures of the proximal femur: a study of 102 consecutive cases over a ten-year period. J Bone Joint Surg Br. 2009;91(8):1064-1068. Review/Other-Dx 102 consecutive patients To investigate the use of MRI in making an early diagnosis and formulating a management plan in patients with no visible fracture of the proximal femur on plain radiographs. There were 98 patients who fulfilled our inclusion criteria, of whom 75 were scanned within 48 hours of admission, with an overall mean time between admission and scanning of 2.4 days (0 to 10). A total of 81 patients (83%) had abnormalities detected on MRI; 23 (23%) required operative management. The use of MRI led to the early diagnosis and treatment of occult hip pathology. There is a high incidence of fractures which are not apparent on plain radiographs, and shows that MRI is useful when diagnosing other pathology such as malignancy, which may not be apparent on plain films. 4
29. Ahovuo JA, Kiuru MJ, Visuri T. Fatigue stress fractures of the sacrum: diagnosis with MR imaging. Eur Radiol. 2004;14(3):500-505. Observational-Dx 380 conscripts Retrospective study to describe the MRI findings and clinical observations in fatigue stress fractures of the sacrum in Finnish military recruits. MRI detected signal abnormalities compatible with sacral stress fractures in 31 patients. The linearity of the fracture lines on MRI is characteristic. MRI should be the procedure of choice for evaluating for sacral stress fractures. 3
30. Anderson MW.. Imaging of upper extremity stress fractures in the athlete. [Review] [56 refs]. Clin Sports Med. 25(3):489-504, vii, 2006 Jul. Review/Other-Dx N/A To review the most common sites of stress injuries in the upper extremity, their underlying pathophysiology, and their spectrum of imaging findings. Although a three-phase bone scan is highly sensitive in this regard, MRI has become the study of choice at most centers. 4
31. Berger FH, de Jonge MC, Maas M. Stress fractures in the lower extremity. The importance of increasing awareness amongst radiologists. [Review] [48 refs]. Eur J Radiol. 62(1):16-26, 2007 Apr. Review/Other-Dx N/A To review stress fractures of the lower extremity. Raised awareness of medical staff and increased athletic activity have increased the incidence of stress fractures, now making up about 15% of the general sports medicine practice. These fractures can affect essentially every bone in the body, but are most frequent in the lower extremity. Timely diagnosis is essential to prevent dramatic consequences for the athlete, yet this is not easy. Thorough knowledge of typical sport mechanics and a high index of suspicion is needed to accurately image a professional or recreational sportsman/woman. 4
32. Campbell SE, Fajardo RS. Imaging of stress injuries of the pelvis. [Review] [60 refs]. Semin Musculoskelet Radiol. 12(1):62-71, 2008 Mar. Review/Other-Dx N/A Review the pathphysiology and imaging appearances of stress injuries of the pelvis and sacrum. Relevant literature regarding risk factors, problem-solving issues, and an imaging algorithm are discussed, with the goal of improving accuracy in the diagnosis of these common injuries. 4
33. Kijowski R, Choi J, Mukharjee R, de Smet A. Significance of radiographic abnormalities in patients with tibial stress injuries: correlation with magnetic resonance imaging. Skeletal Radiol. 2007;36(7):633-640. Observational-Dx 80 patients; 99 tibias evaluated, 2 reviewers Retrospective review. To correlate radiographic findings with MRI findings in patients with suspected tibial stress injuries in order to determine the significance of radiographic signs of stress injury in these individuals. Strong association between the presence of periosteal reaction on radiographs at the site of the clinical symptoms and a Fredericson grade 4 stress injury on MRI. The presence of periosteal reaction on radiographs at the site of clinical symptoms is predictive of a high-grade stress injury by MRI criteria. 2
34. Krestan C, Hojreh A. Imaging of insufficiency fractures. Eur J Radiol. 2009;71(3):398-405. Review/Other-Dx N/A Review occurrence, imaging and differential diagnosis of insufficiency fractures. Radiographs are still the most widely used imaging method for identification of insufficiency fractures, but sensitivity is limited, depending on the location of the fractures. MRI is a very sensitive tool to visualize bone marrow abnormalities associated with insufficiency fractures. Thin section, MDCT depicts subtle fracture lines allowing direct visualization of cortical and trabecular bone. Bone scintigraphy still plays a role in detecting fractures, with good sensitivity but limited specificity. The most important differential diagnosis is underlying malignant disease leading to pathologic fractures. Bone densitometry and clinical history may also be helpful in confirming the diagnosis of insufficiency fractures. 4
35. Lee SH, Baek JR, Han SB, Park SW. Stress fractures of the femoral diaphysis in children: a report of 5 cases and review of literature. J Pediatr Orthop. 2005;25(6):734-738. Review/Other-Dx 5 patients Small report on patients with stress fractures without a history of recent increase in activity. MRI is most useful in diagnosing stress fractures when other causes of leg pain are being considered. 4
36. Nguyen JT, Peterson JS, Biswal S, Beaulieu CF, Fredericson M. Stress-related injuries around the lesser trochanter in long-distance runners. AJR Am J Roentgenol. 2008;190(6):1616-1620. Review/Other-Dx 9 long-distance runners, 2 reviewers Retrospective study to assess the MRI findings associated with symptomatic stress injuries at the lesser trochanter in long-distance runners to develop guidelines for clinical management. Long-distance runners with hip or groin pain and abnormal MRI findings involving the insertion of the iliopsoas tendon and marrow edema in the lesser trochanter may be at risk of stress injuries at the femoral neck. 4
37. Sofka CM.. Imaging of stress fractures. [Review] [19 refs]. Clin Sports Med. 25(1):53-62, viii, 2006 Jan. Review/Other-Dx N/A To review the use of CT, nuclear scintigraphy US, and MRI in patients with suspected stress fractures. Imaging should begin with radiography of the area of question. CT is useful for fine bony detail and endosteal scalloping. Nuclear imaging shows area of stress remodeling. MRI provides the most comprehensive evaluation of stress injuries. 4
38. Sormaala MJ, Niva MH, Kiuru MJ, Mattila VM, Pihlajamaki HK. Stress injuries of the calcaneus detected with magnetic resonance imaging in military recruits. J Bone Joint Surg Am. 2006;88(10):2237-2242. Observational-Dx 30 recruits displayed calcaneal stress injuries Retrospective study to assess the anatomic distribution, nature, and healing of calcaneal stress injuries in a group of military recruits based on MRI. MRI yielded an incidence of 2.6 (95% CI, 1.6 to 3.4) per 10,000 person-years. Most stress injuries of the calcaneus occur in the posterior part of the bone, but a considerable proportion can also be found in the middle and anterior parts. To obtain a diagnosis, MRI is warranted if plain radiography does not show abnormalities in a physically active patient with exercise-induced pain in the ankle or heel. 3
39. Sormaala MJ, Niva MH, Kiuru MJ, Mattila VM, Pihlajamaki HK. Bone stress injuries of the talus in military recruits. Bone. 39(1):199-204, 2006 Jul. Observational-Dx 51 consecutive recruits displayed bone stress injuries; 56 bone stress injuries 3 reviewers Retrospective study to assess the incidence, anatomic distribution, and nature of fatigue bone stress injuries of the talus in military recruits based on MRI. On MRI, the majority of the bone stress injuries of the talus were revealed in the head. A grade IV injury was discovered in 18% of the cases; in the remaining 82%, only grade I-III injuries were ascertained. In all locations, the lower grade bone stress injuries dominated. This study established the incidence of fatigue bone stress injury of the talus and indicated that these injuries are rare but not unseen in military recruits. 3
40. Nachtrab O, Cassar-Pullicino VN, Lalam R, Tins B, Tyrrell PN, Singh J. Role of MRI in hip fractures, including stress fractures, occult fractures, avulsion fractures. Eur J Radiol. 81(12):3813-23, 2012 Dec. Review/Other-Dx N/A To review the current applications of MRI highlighting its benefits and limitations in the use of hip fracture imaging. MRI has proven to be a sensitive, cost effective and efficient modality in the use of fracture imaging. MRI aids in streamlining patient care, can help guiding towards adequate treatment decision making, as well as detecting different causes of the patient symptoms. Although MRI may not be as readily available in some hospitals and more expensive than bone scan and CT, it does however achieve definitive diagnosis much quicker. Overall cost are reduced, hospitalisation stay is less due to a speedier correct diagnosis, correct treatment is started early and the risk of complications reduced. 4
41. Fottner A, Baur-Melnyk A, Birkenmaier C, Jansson V, Durr HR. Stress fractures presenting as tumours: a retrospective analysis of 22 cases. Int Orthop. 33(2):489-92, 2009 Apr. Review/Other-Dx 22 cases To analyse the quality of different examinations in detecting stress fractures mimicking tumour-like lesions in magnetic resonance imaging (MRI). A stress fracture was diagnosed in 15 cases after the additional CT scan, in five cases with the review of the MRI and in two cases with a combination of several examinations. Especially in stress fractures of the tibia and the femur, CT scanning was essential for making a diagnosis by detecting the fracture line. Bone scans and biopsies, in contrast, were not helpful in making a correct diagnosis. 4
42. Nattiv A, Kennedy G, Barrack MT, et al. Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: a 5-year prospective study in collegiate track and field athletes. Am J Sports Med 2013;41:1930-41. Observational-Dx 211 patients To examine the relationships between MRI grading of bone stress injuries with clinical risk factors and time to return to sport in collegiate track and field athletes. Thirty-four of the athletes (12 men, 22 women) sustained 61 bone stress injuries during the 5-year study period. The mean prospective assessment for participants was 2.7 years. In the multiple regression model, MRI grade and total-body bone mineral density (BMD) emerged as significant and independent predictors of time to return to sport. Specifically, the higher the MRI grade (P = .004) and lower the BMD (P = .030), the longer the recovery time. Location of the bone injury at predominantly trabecular sites of the femoral neck, pubic bone, and sacrum was also associated with a prolonged time to return to sport. Female athletes with oligomenorrhea and amenorrhea had bone stress injuries of higher MRI grades compared with eumenorrheic athletes (P = .009). 3
43. Lassus J, Tulikoura I, Konttinen YT, Salo J, Santavirta S. Bone stress injuries of the lower extremity: a review. Acta Orthop Scand 2002;73:359-68. Review/Other-Dx N/A To review bone stress injuries of the lower extremity. Bone stress injuries can cause long-lasting damage, especially in young athletes and military conscripts, if not diagnosed and treated properly. Diagnosis has been traditionally based on clinical, radiographic and scintigraphic examinations, but MRI has become increasingly important. High resolution MRI is particularly valuable for the grading of bone stress injuries. The clinician should be aware of the wide range of bone stress injuries and available diagnostic methods. Early diagnosis is the prerequisite for avoiding long-lasting complications. Most bone stress injuries heal with closed treatment, but surgery is necessary in some cases. They heal well if the diagnosis is not delayed and the treatment adequate 4
44. Banal F, Gandjbakhch F, Foltz V, et al. Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients. J Rheumatol. 36(8):1715-9, 2009 Aug. Observational-Dx 37 patients To evaluate sensitivity and specificity of US versus dedicated MRI (0.2 Tesla), taken as the gold standard, in early diagnosis of metatarsal bone stress fractures. Forty-one feet were analyzed on US and dedicated MRI from 37 patients (28 women, 9 men, mean age 52.7 +/- 14.1 yrs). MRI detected 13 fractures in 12 patients. Sensitivity of US was 83%, specificity 76%, positive predictive value 59%, and negative predictive value 92%. Positive likehood ratio was 3.45, negative likehood ratio 0.22. 2
45. Bianchi S, Luong DH. Stress fractures of the ankle malleoli diagnosed by ultrasound: a report of 6 cases. Skeletal Radiol. 43(6):813-8, 2014 Jun. Review/Other-Dx 6 patients To present the ultrasound appearance of stress fractures (SF) of the ankle malleoli. At ultrasound patients showed thickening of the periosteum in all patients, calcified bone callus was evident in 3 out of 6 patients. Cortical irregularities and subcutaneous oedema were found in all but one patient. Colour Doppler showed local hypervascular changes in all patients. Local compression with the transducers during real-time scanning increased pain in all cases. 4
46. Banal F, Etchepare F, Rouhier B, et al. Ultrasound ability in early diagnosis of stress fracture of metatarsal bone. Ann Rheum Dis 2006;65:977-8. Review/Other-Dx 1 patient To report a case of ultrasound diagnosis of metatarsal stress fracture. No results stated in abstract. 4
47. Tsiridis E, Upadhyay N, Giannoudis PV. Sacral insufficiency fractures: current concepts of management. Osteoporos Int 2006;17:1716-25. Review/Other-Dx N/A To raise awareness and outline the clinical presentation, methods of diagnosis and treatment of SIFs. Insufficiency fractures represent a special category of stress fractures that occur in bones with reduced mineral content and elastic resistance. SIFs, a well-defined subgroup of the latter group, are not uncommon, but lack of clinical suspicion results in many being undiagnosed. SIFs are set to become an important clinical entity of both social and economic significance as the Western population ages. Subtle clinical presentations and signs coupled with radiographic findings that can mimic other unrelated or overlapping conditions, such as sacroiliac joint infection, spinal stenosis and metastatic bone disease, often make SIF diagnosis a challenge. 4
48. Schmid L, Pfirrmann C, Hess T, Schlumpf U. Bilateral fracture of the sacrum associated with pregnancy: a case report. Osteoporos Int. 1999;10(1):91-93. Review/Other-Dx 1 case To describe a 33-year-old woman with a bilateral fracture of the sacrum associated with pregnancy. Dual-energy X-ray absorptiometry of the lumbar spine and femoral neck showed normal bone mineral density, whereas bilateral osteopenic areas in the massae laterales were demonstrated by the initial CT-scan. 4
49. Breuil V, Brocq O, Euller-Ziegler L, Grimaud A. Insufficiency fracture of the sacrum revealing a pregnancy associated osteoporosis. First case report. Ann Rheum Dis. 1997;56(4):278-279. Review/Other-Dx 1 case A case reprt on the insufficiency fracture of the sacrum revealing a pregnancy associated osteoporosis. No results stated in abstract. 4
50. Karatas M, Basaran C, Ozgul E, Tarhan C, Agildere AM. Postpartum sacral stress fracture: an unusual case of low-back and buttock pain. Am J Phys Med Rehabil. 2008;87(5):418-422. Review/Other-Dx 1 case A case of postpartum sacral stress fracture. To date, only eight postpartum sacral stress fractures have been reported in the literature. A 32-yr-old woman presented with low-back and right buttock pain that started 15 days after uneventful cesarean section delivery. Imaging studies revealed a right sacral stress fracture. Lumbar spine and femoral neck bone mineral density were normal and, except for pregnancy and lactation, no risk factors for osteoporosis were identified. There was no history of trauma, excessive weight gain, strenuous physical activity, or contribution of mechanical factors. The question remains whether this is an insufficiency fracture or a fatigue fracture. Clinicians should consider sacral fracture during pregnancy and the postpartum period as a diagnostic possibility in patients with low-back and/or buttock pain. 4
51. Lin JT, Lutz GE. Postpartum sacral fracture presenting as lumbar radiculopathy: a case report. Arch Phys Med Rehabil. 2004;85(8):1358-1361. Review/Other-Dx 1 case To present a case of a young, postpartum, recreational runner who developed low back pain (LBP) and radicular symptoms suggestive of L5 radiculopathy found to be secondary to sacral stress fracture. Sacral stress fractures are a rare entity that may occur in exercising postpartal women. The specific explanation for these fractures remains unclear. Symptoms include LBP and radicular pain, which may initially be attributed to a diskogenic cause. Overall, these patients have a good clinical outcome. Rehabilitation, including light weight-bearing exercise, is essential for bone healing and may be performed with the use of adequate pain control. Underlying causes for fracture, such as osteoporosis or other metabolic bone disease, should ideally be ruled out to correct potentially treatable conditions. Clinicians caring for postpartum exercising women should have a high clinical suspicion for sacral stress fracture in patients with low-back, buttock, or groin pain. 4
52. Rousiere M, Kahan A, Job-Deslandre C. Postpartal sacral fracture without osteoporosis. Joint Bone Spine. 2001;68(1):71-73. Review/Other-Dx 1 case To report a new case of nontrauma-related postpartal sacral fracture. Pregnancy-related sacral fractures are uncommon but should be considered by rheumatologists in the differential diagnosis of buttock pain during pregnancy or the early postpartal period. Magnetic resonance imaging usually provides the diagnosis. Increased awareness of pregnancy-related sacral fractures through the publication of case reports will increase the number of diagnosed cases. 4
53. Thein R, Burstein G, Shabshin N. Labor-related sacral stress fracture presenting as lower limb radicular pain. Orthopedics. 2009;32(6):447. Review/Other-Dx N/A To review sacral stress fractures. No results stated in abstract. 4
54. Thienpont E, Simon JP, Fabry G. Sacral stress fracture during pregnancy--a case report. Acta Orthop Scand. 1999;70(5):525-526. Review/Other-Dx 1 case A case report of sacral stress fracture during pregnancy. No results stated in abstract. 4
55. Leroux JL, Denat B, Thomas E, Blotman F, Bonnel F. Sacral insufficiency fractures presenting as acute low-back pain. Biomechanical aspects. Spine (Phila Pa 1976) 1993;18:2502-6. Review/Other-Dx 10 cases To describe 10 cases of spontaneous sacral insufficiency fractures, confirmed by computed tomography, characterized by the onset of acute low-back pain. Sacral insufficiency fractures are an often unsuspected cause of low-back pain in elderly women with osteopenia who have sustained unknown or only minimal trauma. Differential clinical and radiographic diagnosis of these fractures is often difficult. Recognition of the characteristic scintigraphic patterns in sacral fractures, which are frequent in osteopenic patients, could avoid mistaken diagnoses and unnecessary tests or treatment. One of the striking feature of these sacral fractures is their invariable location. The fractures extend vertically in the sacral alae, parallel to the sacroiliac joints. They are located just lateral to the margins of the lumbar spine. This distribution suggests that such fractures could be partially caused by weight-bearing transmitted through the spine. 4
56. Beltran LS, Bencardino JT. Lower back pain after recently giving birth: postpartum sacral stress fractures. Skeletal Radiol. 2011;40(4):461-462, 481-462. Review/Other-Dx 1 case A case report of a woman presented to the emergency room with severe lower back pain after recently giving birth. No results stated in abstract. 4
57. Steib-Furno S, Luc M, Pham T, et al. Pregnancy-related hip diseases: incidence and diagnoses. Joint Bone Spine. 2007;74(4):373-378. Review/Other-Dx N/A To report the incidence of gestational and postpartum hip diseases and evaluate their incidence. During the 2-year prospective survey, 3 patients (4 hips) of pregnancy-related hip disease were observed over 4900 pregnancies (1 case of transient osteoporosis of the hip (TOH) and 2 cases of occult fracture of the femoral head). During the 15-year retrospective study, 12 patients (17 hips) with hip diseases during pregnancy or early postpartum were identified. There were 6 patients (9 hips) with TOH, 4 patients (6 hips) with occult fracture of the femoral head, 1 patient with osteonecrosis of the femoral head, and 1 coxitis in a patient with ankylosing spondylitis. Differentiating diagnosis between TOH and occult fractures could only be made by MRI. Five of the 6 women with TOH had osteopenia at the lumbar spine at dual energy X-ray absorptiometry (DEXA). The 4 women with occult fractures had either osteopenia or osteoporosis at the lumbar spine. 4
58. Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress fractures of the pelvis and legs in athletes: a review. Sports Health 2013;5:165-74. Review/Other-Dx N/A To review the literature regarding stress fractures of the pelvis and legs in athletes. Intrinsic and extrinsic factors may predict the risk of stress fractures in athletes, including bone health, training, nutrition, and biomechanical factors. Based on their location, stress fractures may be categorized as low- or high-risk, depending on the likelihood of the injury developing into a complete fracture. Treatment for these injuries varies substantially and must account for the risk level of the fractured bone, the stage of fracture development, and the needs of the patient. High-risk fractures include the anterior tibia, lateral femoral neck, patella, medial malleolus, and femoral head. Low-risk fractures include the posteromedial tibia, fibula, medial femoral shaft, and pelvis. Magnetic resonance is the imaging test of choice for diagnosis. 4
59. Fullerton LR, Jr., Snowdy HA. Femoral neck stress fractures. Am J Sports Med 1988;16:365-77. Observational-Dx 49 patients To review our results as to classification, incidence, race of patients, bone scintigraphy, and treatment of femoral neck stress fractures. No results stated in abstract. 3
60. Monteleone GP, Jr. Stress fractures in the athlete. Orthop Clin North Am 1995;26:423-32. Review/Other-Dx N/A To describe stress fractures in athletes. Stress fractures are common injuries in the athletic population. High clinical suspicion is required for the diagnosis because of vague historical and physical features. Bone scans are the gold standard of diagnosis, though MR imaging and CT may be helpful adjuncts. Most stress fractures do very well with the nonsurgical treatment approach. Some fractures of the proximal diaphysis of the fifth metatarsal, femoral neck fractures, and any displaced, completed fracture require surgery. Consideration must also be given for correctable risk factors and preventive measures must be addressed. 4
61. DeFranco MJ, Recht M, Schils J, Parker RD. Stress fractures of the femur in athletes. Clin Sports Med 2006;25:89-103, ix. Review/Other-Dx N/A To describe the pathoanatomy, cause, clinical assessment, and treatment options will facilitate the care of athletes with a femoral stress fracture and the return to a preinjury level of competition. Femoral stress fractures represent an uncommon but important lower-extremity injury in athletes and soldiers. Careful assessment of the involved and contralateral lower extremity and the spine is required to make the diagnosis. Based on a review of the literature, specific treatment is based on individual patient assessment. In most cases, nonoperative management results in an excellent outcome. Certain fractures will require operative intervention to prevent displacement or to reduce a displaced fracture and return stability to the lower extremity. Complications in athletes with femoral stress fractures are rare. Most athletes can expect to return to their preinjury level of competition, if they are compliant with the treatment plan. 4
62. ICRP, 2000. Pregnancy and Medical Radiation. ICRP Publication 84. Ann. ICRP 30 (1).  Available at: http://www.icrp.org/publication.asp?id=ICRP%20Publication%2084. Review/Other-Dx N/A To discuss the management of pregnant patients as well as pregnant workers in medical establishments where ionizing radiation is used. No results stated in abstract. 4
63. Goolsby MA, Barrack MT, Nattiv A. A displaced femoral neck stress fracture in an amenorrheic adolescent female runner. Sports Health 2012;4:352-6. Review/Other-Dx 1 case A case report to demonstrate the potential serious consequences of the female athlete triad and its effects on bone. Displaced femoral neck stress fractures cause significant morbidity, and this case highlights the preventable nature of this injury. The treatment was focused on improving low energy availability, and, although challenging, improvements were made. This injury could have been prevented if the signs and symptoms of her injury had been addressed and there had been better knowledge of her risk factors. This case highlights the need for further education in the sports and health communities. 4
64. Jones BH, Thacker SB, Gilchrist J, Kimsey CD, Jr., Sosin DM. Prevention of lower extremity stress fractures in athletes and soldiers: a systematic review. Epidemiol Rev 2002;24:228-47. Review/Other-Dx 423 scientific publications To review the reported research on the causes of and risk factors for stress fracture, to determine what is known about the prevention of stressfracture and to make recommendations for a systematic approach to future research and prevention. This review summarizes an extensive body of literature on stress fractures. It also highlights how little we know about what works to prevent one of the most common and potentially serious sports- and exercise-related overuse injuries. The available research suggests that for many persons, stress fractures and other physical training-related injuries can be prevented by reducing the amounts of weight-bearing exercise performed without sacrificing fitness. The data also suggest that the most sedentary and least physically fit persons are most vulnerable to stress fractures when starting a vigorous exercise program and that they would benefitmost from starting exercise gradually and reducing training volume. Until more definitive solutions become available, a common-sense approach to training and overuse injury prevention must be recommended. 4
65. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53. Review/Other-Dx N/A To describe the evaluation and treatment of high-risk stress fractures. No results stated in abstract. 4
66. Bencardino JT, Kassarjian A, Palmer WE. Magnetic resonance imaging of the hip: sports-related injuries. [Review] [62 refs]. Top Magn Reson Imaging. 14(2):145-60, 2003 Apr. Review/Other-Dx N/A To review use of conventional radiography and MRI in recreational and professional athletes with painful hip joints. In patients with suspected sports related stress fractures of the hip and normal radiographs, MRI of the entire pelvis should be the next imaging modality for evaluation. 4
67. Fujii M, Abe K, Hayashi K, et al. Honda sign and variants in patients suspected of having a sacral insufficiency fracture. Clin Nucl Med 2005;30:165-9. Review/Other-Dx 34 bone scans of 26 patients To reassess whether the Honda sign (HS) and its variants on bone scans can be used to differentiate an insufficiency fracture (IF) of the sacrum from a metastasis and to evaluate extrapelvic tracer accumulation in patients suspected of having a sacral IF. Twenty-four of the patients had a sacral IF and 1 had a sacral metastasis from prostate cancer and another from lung cancer. The bone scans of only 15 (63%) of the 24 patients with a sacral IF exhibited the HS, 8 (33%) scans exhibited variants, and 4 (4%) scans showed whole-sacrum uptake. One of the 2 patients with metastasis exhibited the HS and the other exhibited a variant. The sensitivity and positive predictive value of HS plus its variants as diagnostic criteria for sacral IF were 96% and 92%, respectively. Seventeen patients (71%) had extrasacral accumulation. The most common site was the pubic bone (50%, 12 of 24), and the second most common site was the spine (46%, 11 of 24), where the accumulation was the result of a compression fracture or degenerative joint disease of the spine. 4
68. Brenner AI, Koshy J, Morey J, Lin C, DiPoce J. The bone scan. Semin Nucl Med 2012;42:11-26. Review/Other-Dx N/A To review the clinical strength of planar bone imaging, in comparison with single-photon emission computed tomography (SPECT), SPECT/CT, 18F-fluorodeoxyglucose (FDG), and positron-emission tomography (PET) imaging and briefly reviews the re-emergence of 18F sodium fluoride bone PET imaging. The power of bone imaging lies in the physiological uptake and pathophysiologic behavior of 99 m-Tc diphosphonates. Its clinical utility, sensitivity and specificity was established based on planar imaging data. Planar bone imaging data are often sufficient for diagnosis and may be enhanced by SPECT. New imaging modalities, including 18F-FDG-PET, CT and MR are complementary to 99 -m-Tc bone imaging. 18F-FDG-PET and 99m-Tc bone imaging reflect different biological processes (FDG uptake by tumor cells; MDP uptake by osteoblastic activity). We can lower radiation doses by prescribing lower injected doses and minimizing unnecessary additional imaging. We are physicians and should all adopt a “value-added” approach to image interpretation. 4
69. Ha AS, Chang EY, Bartolotta RJ, et al. ACR Appropriateness Criteria® Osteonecrosis: 2022 Update. J Am Coll Radiol 2022;19:S409-S16. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for osteonecrosis. No results stated in abstract. 4
70. Yu JS, Krishna NG, Fox MG, et al. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol 2022;19:S417-S32. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for osteoporosis and bone mineral density. No results stated in abstract. 4
71. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 1995;23:472-81. Review/Other-Dx 14 runners To evaluate tibial stress injuries in runners, develop a grading system based on MRI findings, and try to identify clinical parameters correlating with more severe grades of injury. Medial tibial pain in runners has traditionally been diagnosed as either a shin splint syndrome or as a stress fracture. Our work using magnetic resonance imaging suggests that a progression of injury can be identified, starting with periosteal edema, then progressive marrow involvement, and ultimately frank cortical stress fracture. Fourteen runners, with a total of 18 symptomatic legs, were evaluated and, within 10 days, referred for radiographs, a technetium bone scan, and a magnetic resonance imaging scan. In 14 of the 18 symptomatic legs, magnetic resonance imaging findings correlated with an established technetium bone scan grading system and more precisely defined the anatomic location and extent of injury. We identified clinical symptoms, such as pain with daily ambulation and physical examination findings, including localized tibial tenderness and pain with direct or indirect percussion, that correlated with more severe tibial stress injuries. When clinically warranted, we recommend magnetic resonance imaging over bone scan for grading of tibial stress lesions in runners. Magnetic resonance imaging is more accurate in correlating the degree of bone involvement with clinical symptoms, allowing for more accurate recommendations for rehabilitation and return to impact activity. Additional advantages of magnetic resonance imaging include lack of exposure to ionizing radiation and significantly less imaging time than three-phase bone scintigraphy. 4
72. Beck BR, Bergman AG, Miner M, et al. Tibial stress injury: relationship of radiographic, nuclear medicine bone scanning, MR imaging, and CT Severity grades to clinical severity and time to healing.[Erratum appears in Radiology. 2012 Sep;264(3):920]. Radiology. 263(3):811-8, 2012 Jun. Observational-Dx 40 patients To examine the relationship between severity grade for radiography, triple-phase technetium 99m nuclear medicine bone scanning, magnetic resonance (MR) imaging, and computed tomography (CT); clinical severity; and recovery time from a tibial stress injury (TSI), as well as to evaluate interassessor grading reliability. Image assessment reliability was high for all grading systems except radiography, which was moderate (alpha = 0.565-0.895). Clinical severity was negatively associated with MR imaging severity (P </= .001). There was no significant relationship between time to healing and severity score for any imaging modality, although a positive trend existed for MR imaging (P = .07). 3
73. Yao L, Johnson C, Gentili A, Lee JK, Seeger LL. Stress injuries of bone: analysis of MR imaging staging criteria. Acad Radiol 1998;5:34-40. Observational-Dx 35 patients To examine the prognostic value of magnetic resonance (MR) imaging in stress injuries of bone. The MR imaging finding of a "fracture" or "fatigue" line or a cortical signal intensity abnormality was predictive of a longer symptomatic period, whereas muscle edema was predictive of a shorter symptomatic period. A published grading system could be used in only 24 patients; the MR imaging grade of injury did not show correlation with clinical outcome. 3
74. Kijowski R, Choi J, Shinki K, Del Rio AM, De Smet A. Validation of MRI classification system for tibial stress injuries. AJR Am J Roentgenol 2012;198:878-84. Observational-Dx 138 patients including 142 tibial stress injuries To compare an MRI classification system for tibial stress injuries with semiquantitative MR features of injury severity and clinical outcome. Grade 4b injuries had significantly (p < 0.002) more severe and grade 1 injuries less severe periosteal and bone marrow edema than grades 2, 3, and 4a injuries. Grade 4b injuries had significantly (p < 0.002) longer time and grade 1 injuries shorter time to return to sports activity than grades 2, 3, and 4a injuries. There was no significant difference (p = 0.06-0.79) among grades 2, 3, and 4a injuries in the degree of periosteal and bone marrow edema and the time to return to sports activity. 3
75. American College of Radiology. ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/mr-fetal.pdf Review/Other-Dx N/A To promote safe and optimal performance of fetal magnetic resonance imaging (MRI). No abstract available. 4
76. American College of Radiology. ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Pregnant_Patients.pdf. Review/Other-Dx N/A To assist practitioners in providing appropriate radiologic care for pregnant or potentially pregnant adolescents and women by describing specific training, skills and techniques. No abstract available. 4
77. American College of Radiology. ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound. Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/us-ob.pdf Review/Other-Dx N/A To promote the safe and effective use of diagnostic and therapeutic radiology by describing the key elements of standard ultrasound examinations in the first, second, and third trimesters of pregnancy. No abstract available. 4
78. American College of Radiology. ACR Committee on Drugs and Contrast Media. Manual on Contrast Media. Available at: https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf. Review/Other-Dx N/A Guidance document to assist radiologists in recognizing and managing the small but real risks inherent in the use of contrast media. No abstract available. 4
79. American College of Radiology. ACR Committee on MR Safety. 2024 ACR Manual on MR Safety. Available at: https://www.acr.org/-/media/ACR/Files/Radiology-Safety/MR-Safety/Manual-on-MR-Safety.pdf. Review/Other-Dx N/A Guidance document to promote the use of magnetic resonance (MR) safe practices. No abstract available. 4
80. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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